ADVANCED PLANNING EMPLOYMENT STATUS:

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1 ADVANCED PLANNING Full Name (first, middle, last): Name for Newspaper/Nick Name: Address-Permanent (city, state, zip): Address-Other (city, state, zip): Sex: Male Female Ethnicity: White Black American Indian Other Social Security Number: Funeral directors are required to make notification of a death to Social Security via Form SSA-721 (Statement of Death by Funeral Director). Please know, survivor s benefits are NOT automatically distributed upon receipt of Form SSA-721, rather a surviving spouse or dependent child (or their representative) must make application. For more information about Social Security Benefits visit or call toll-free (or contact the Creston, Iowa Office of Social Security at ). Date of Birth (month, day, year): Place of Birth (city, state): Education: No Formal Education GED High School - # of years completed Name of High School: Year of Graduation: Name of College/Institution: # of Years Completed: Degree(s): Father s Full Name (first, middle, last): Mother s Full Name (first, middle, include maiden name): Marital Status: Single Married Widowed Divorced Spouse s Full Name (first, middle, include maiden name): If spouse is deceased, list date of death: Date and Place of Marriage: EMPLOYMENT STATUS: Retired (Year ) Presently Employed Not Employed Usual Occupation: Kind of Business/Industry: Employer: # of Years: Employment History: If death occurs while currently employed (not retired), contact the employer and/or union regarding benefits available to survivors. Also, inquire about a final paycheck and determine if there is a 401K, pension and/or company stock benefits. If death was work related, find out if this will affect benefits. If the deceased was retired, determine if survivors will continue to receive pension payments and if a spouse s medical coverage was part of the deceased employment and determine if coverage can continue.

2 MILITARY SERVICE: Veteran: Yes No Copy of Discharge: Yes No Branch of Service: Rank: Service Dates: VA Service Number: Ochiltree Funeral Service routinely applies for Veteran Benefits on behalf of the veteran s family to confirm possible eligibility. A copy of the veteran s discharge is required when applying for benefits (Forms: DD214 or NB22). Benefits may include: burial benefits/plot allowances, headstone/grave marker, flag and burial in a state owned and managed veterans cemetery or a national cemetery (i.e. Iowa Veterans Cemetery or Arlington Cemetery). If the veteran was receiving disability benefits connected to their service or if death occurs in a veteran s hospital, additional benefits may apply. You may contact the Veterans Association toll-free at or go online at AFFILIATIONS AND INTERESTS: (Church, Clubs, Organizations, Memberships, Passions, Hobbies,.) Special Stories/Memories: _ Favorites (Colors, Flowers, Movies, People, Books, Foods, Places, Events, ) SURVIVORS: Spouse (City and State): Parents (City and State): Children (City and State): _

3 Sisters/Brothers (City and State): Grandchildren - # Great Grandchildren - # Great-Great Grandchildren - # Other Survivors: Preceded in Death by: Spouse: Parents: Children: Siblings: Grandchildren: Include the names of spouses, grandchildren, great grandchildren and great-great grandchildren; all of whom can be included in an expanded obituary for publication. Make sure to confirm spelling of names. VISITATION / GATHERING: Location of Visitation: Funeral Home Other: Special requests related to visitation: _ Fraternal Services: Yes No Masonic Eastern Star Rebekahs Knights of Columbus Other: Fraternal Notes: FUNERAL CEREMONIES: Traditional Funeral Mass of Christian Burial Graveside Memorial Service Location of Service: Clergy/Service Leader:

4 Eulogy/Memories: Scripture/Readings/Poems: Other Special Requests: Luncheon/Reception: Yes No Location: Details: Military Honors: Yes No Location: Details: Veterans Flag: Drape Casket Folded (for display) No Flag Donate Flag - VFW Avenue of Flags Present Flag to: MUSIC SELECTIONS: Recorded Organ Piano Other: Organist / Pianist: Soloist: Selections: (include name of song/artist): _ Music is an important part of any ceremony and families typically incorporate songs which remind them of their loved one or give them strength and encouragement during their time of grief. When selecting songs, keep in mind two or three selections is average and be mindful that the songs you select are appropriate for the public. Whether your preference is recorded music or a live musician, we will help to coordinate. Pallbearers: Pallbearers are given the honor of carrying a loved one or friend to their final resting place. With this in mind, make certain those asked to perform this honor are physically able to carry a casket and are comfortable doing so. Typically, six pallbearers are requested, however, four will work and many times families have more than six. Pallbearers can be women or men and many times, are grandchildren. Pallbearers can carry an urn to a gravesite as well. Honorary Pallbearers:

5 Honorary Pallbearers are similar to Pallbearers minus the responsibly to carry a casket or urn. As the name implies, they are given the honor of being listed and many times are family and friends who are physically unable to carry a casket or are unable to be present for a service. Memorial Contributions: FINAL DISPOSITION Burial Cremation (Return to Family) Cremation (Burial) Other: Cemetery: City/Town/County/Township: Lot Owner: Distribution and Division of Cremated Remains: OTHER DETAILS Jewelry/Accessories (indicate what is to be removed prior to burial or cremation): Clothing: Traditional attire such as a suit or dress are common selections, however, if a baseball cap, jeans or special sweater is more your style, then by all means these options should be considered. Also, undergarments are always used and the use of shoes is up to the individual family. Please know, we make every attempt to NOT alter clothing provided to us unless it is absolutely necessary. Flowers (type, color, special requests): Newspapers (Include Photo Yes No): Certified Death Certificates (# to order): Certified Death Certificates are used to help complete much of the legal business related to the deceased. One of the many responsibilities of a funeral director is to see that the death is certified and recorded in the county where death occurs. Certified copies of a death certificate are often required to settle many areas of business including but not limited to; banking, life insurance, investment, 401K plans, IRA s, property (titles and deeds) and more. It is always wise to consult your banker, insurance agent and attorney about specifics related to how many certified copies of a death certificate you might need. The funeral director will gather the required information to be recorded on the death certificate from the family and electronically create the document via the State of Iowa Electronic Death Registry System. Once the deceased has been entered into the electronic system, the record is sent to the doctor who will record the cause of death. Upon completion by the doctor, the record is returned to the funeral home for review and will be sent to the county recorder s office where it will be certified. Certified copies of a death certificate can be obtained from any recorder s office in the state of Iowa regardless of where the death has occurred. Only family of the deceased can obtain certified copies of a death record (the funeral director can on a family s behalf for one year following a death). Certified death certificates from Iowa are NOT to be photocopied. Since it is a public record, anyone can obtain an uncertified copy of a death record from the county recorder s office.