Please fill out this questionnaire to the best of your ability to insure that the eulogy expresses your loved one's true self.

1) Name of departed:

2) Date and place of birth:

3) Name(s) of departed's parents:

4) Nature of the death (old age, illness, accident, etc:

5) Marital status (please check appropriate choice(es):
__Married __Single __Divorced
__Widow/Widower __Remarried

If appropriate please provide a brief description of the departed's marital life:

6) Departed's sibling(s) name(s) and age(s):

7) Child/Children's name(s) and age(s):

8) Grandchild/children's name(s) and age(s):

9) Career/Employment of departed:

10) Religious affiliation of departed:

11) Membership in Clubs/Organizations:

12) Hobbies/Interests:

13) Special moment/story about departed:

14) Humorous moment/story about departed:

15) Virtues/special qualities:

16) Additional comments(Please use this space for any thoughts or comments you might have or for additional comments to questions asked above):

17) Name of person filling out this questionnaire: Home Phone:
Work Phone:
Cell Phone:
Email: