Emergency Record Guide

Wadlow Rozanek Funeral and Cremation Services

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Emergency Record Guide

Pre-Planning Funeral Record

Leaving family members with the burden of funeral arrangements may be leaving them hurt, confused and overwhelmed. This form lets you gather the necessary details now and it will take a fraction of the time that would take your family. There is no charge for this valuable service. Just a peace of mind. Thank you for taking the time to fill out all the text boxes. If you have any questions please call us today: 402.467.5200. We will only contact you by e-mail.

First Name: *
Middle Name: *
Last Name: *
Address Street : *
City: *
State:
County:
Zip Code: *	(5 digits)
Telephone: *
email: *
Gender:
Race:
Ancestry:
Date and Place of Birth:
Marital Status:
Spouse (Maiden ) Name:
If deceased, give date of death:
Fathers Name:
Mothers Name:
Date and Place of Marriage:
Doctor's Name and Address:
Education:
Occupation/Employer/Position Held/ How Long:
Organizations, Volunteer, Lodges, Memberships, Etc.:
General Biography for the media:
Hobbies:
If Veteran give branch, war and serial number:
Date entered and discharge, rank and honors received:

Religion:
Church:

Name of cemetery and location:
Type of Funeral Service:
Prayer or Wake Service/Rosary:
Memorial Fund / Masses:
Favorite bible passages, verses, poetry, quotations, etc.:
Hymns / Special Songs
Participating Organizations (Fraternal/Military Rites):
Pallbearers:
Honorary Pallbearers:

Special Instructions:

I have given the preceding information, to be filed in the funeral home in order to avoid placing all responsibility on family and loved ones at the time of my death.