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Name:

Name Known by:

Maiden Name:

Residence Address:

City:

State:

ZipCode:

Township:

County:

Gender:

Date of Birth:

Place of Birth:

US Citizen:

Social Security Number:

Phone #:

Race:

Heritage:

Hispanic Origin:

Highest Level of Education Completed:

Education Details:

Occupation:

Type of Business/Industry:

Marital Status:

Spouse's Name:

Deceased:

Spouse's Address:

Spouse's Phone:

Spouse's Email:

Previous Spouses:

Father's Name:

Deceased:

Mother's Name:

Mother's Maiden Name:

Deceased:

Hobbies:

Organizations: (Church, Lodge, Association)

U.S. Armed Forces Member:

Branch:

Rank:

Years of Service:

Service Number:

Awards, Medals, Places of Service:

Surviving Children:

Surviving Grandchildren, Great Grandchildren, Great-Great Grandchildren:

Surviving Brothers & Sister:

Deceased Family Members:

Additional Persons to Listed in the Obituary:

Memorial Contributions to:

Type of Service Desired:

Service Location:

Officiating:

Music for Service:

Cemetery:

Grave Location:

Pallbearers:

Special Instructions:

I would like to meet with a funeral director to choose casket, vault, urn or printed materials:

YES

269-788-9800

375 W. Dickman Road

Battle Creek, MI 49037

Fax: 269-788-3125

Email: bfcs@baxterfuneral.com

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