Thompson-Miller Funeral Home, Inc.
124 East North Street, Butler, Pennsylvania 16001
Glenn T. Miller, Supervisor
724-287-3706 (office) 724-287-3705 (fax)
Pre-Arrangement Fact Sheet
The following information is needed at the time of your pre-arrangement meeting.
Please Print
Full Name Nickname Age
Address
City State Zip
Township County
Social Security number
Where were you born?
Birth date
Father’s name
Mother’s name (with maiden name)
Work History
Where did you work?
If you are retired, what date?
Spouse’s Name
Date you were married
Date of death, if your spouse is deceased
Are you a member of a church?
Name of Church
Do you belong to any Organizations/Community Activities/Clubs? Please list:
What are your interests or hobbies? Please list:
Education:
High School you attended
How many years did you attend?
College you attended
How many years did you attend?
What degree did you receive?
Military:
Were you in the Military?
What branch
Rank when you were discharged
Did you serve during peace time/war time?
Where did you serve?
Are you able to find your discharge papers? (DD-214)
(The funeral home will need a copy)
Survivors: (Please also indicate the city and state in which they live)
Spouse/Parents/Children/Grand-children/Brothers/Sisters/Nieces/Nephews
Spouse: survivingParents: surviving
Sons: City & State / Brothers: City & State
Daughters: City & State / Sisters City & State
Grandchildren (the number of or list by name) / Nieces (the number of or list by name)
Great-Grandchildren (the number of/ or list by name) / Nephews (the number of or list by name)
Preceded in death:
Funeral Service:
Where would you like the funeral service to be held? Church or Funeral Home
What pastor/lay-minister would you like to perform the service?
What church is the pastor/lay-minister from?
Cemetery:
Cemetery name
Do you own space/spaces there?
Will you be buried beside someone?
Memorials:
Who should memorial donations be made to?
Is this in lieu of flowers? Yes _____ No _____
Contact Person and/or who will be next of kin at the time of need:
Name relationship
Address phone #
Social Security number
Please call to schedule an appointment at your convenience
Thompson-Miller Funeral Home, Inc.
124 East North Street, Butler, Pennsylvania 16001
724-287-3706 (office) 724-287-3705 (fax)
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