PRE-PLANNING BENEFITS|FUNDING OPTIONS|PRE-PLANNING GUIDE

 

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PARKERSBURG | 403 7th St. | Parkersburg, WV  26101 | (304) 422-6459 
BELPRE | 801 Victor St. | Belpre, OH  45714 | (740) 423-6326
 
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Pre-arrangement
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Memorial Obituaries
Contact Us
Leavitt Family Center

PRE-PLANNING GUIDE

Last, please take the time to fill out the following form, which, upon submission, will alert one of our staff members to review and respond to you for follow up.

NOTE: Fields marked with an asterisk ( * ) are required. Any information you submit will be held in the strictest confidence - we do not release any information to outside parties under any circumstances.

Information about person for whom pre-planning is being done:

I am Planning for:
* First Name:
Middle Name:
* Last Name:
* E-mail:
Street Address:
City:
County:
State:
Zip Code:
Telephone Number:
Telehone Number of Person Filling out this Form (if different than above):
Date of Birth (mm/dd/yyyy):
City of Birth:
State of Birth:
Country of Birth:
Social Security Number:
Education - Years Completed:
Race:
Sex: Male Female
 
Marital Status: Married
Never Married
Widowed
Divorced Veteran
(Copy of discharge papers will be needed):		 Yes No
 
Occupation
(Present or before retirement):
Employer:
 
Name of Spouse - First:
Name of Spouse - Maiden or Last:
(Check box if deceased)
Name of Father - First:
Name of Father - Last:
(Check box if deceased)
Name of Mother - First:
Name of Mother - Maiden:
(Check box if deceased)

Other Information & Special Instructions

Please list any other instruction or information you would like us to have:



Options

Please select one of the options below:
Send information about pre-arrangement
Contact me to set an appointment
Please keep my information on file