Coker Funeral Home

Click here for printable PDF version which can be filled out by pen. PDF is Viewable through the Adobe Acrobat Reader, if you do not have the reader click here to install it.

Personal Information

First Name:
Middle Name:
Last Name:
Date of Birth:
Birthplace:
Address:
City:
State/Province:
Zip/Postal Code:
Race:
Marital Status:

Father's Name:
Place of Birth:
State:
If Living/City of Residence:
State/Province:
Zip/Postal Code:

Mother's Maiden Name:
Place of Birth:
State:
If Living/City of Residence:
State/Province:
Zip/Postal Code:

Where was deceased raised?

Highest level of education:

Maiden Name of Spouse:
Date of Marriage:
Place:
If deceased, date of death:

Where has deceased lived during his/her adult life?

Name of children & their spouses, and their addresses

Child#1 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:

Child#2 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:

Child#3 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:

Child#4 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:

Child#5 Name:
Spouse's Name:
Address:
City:
State/Province:
Zip/Postal Code:

Current Number of Grandchildren:
Current Number of Great Grandchildren:

Names of surviving brothers & sisters and their addresses

Sibling#1 Name:
Address:
City:
State/Province:
Zip/Postal Code:

Sibling#2 Name:
Address:
City:
State/Province:
Zip/Postal Code:

Sibling#3 Name:
Address:
City:
State/Province:
Zip/Postal Code:

Sibling#4 Name:
Address:
City:
State/Province:
Zip/Postal Code:

Sibling#5 Name:
Address:
City:
State/Province:
Zip/Postal Code:

Preceded in death by

Occupation. Give the type of work done most of working life, even if retired.

Name of Employer:

If Retired, Date of Retirement:
Total years spent in your occupation:

Church affiliation & activities:

Did deceased serve in the military? Yes No

If yes, what branch:

Service #, War, Date of Entry, & Date of Discharge:

Civic & Professional Organizations:

FUNERAL INSTRUCTIONS

Place of Service:

Minister:

Music Selections:

Organist:

Singer(s):

Singer#1:

Singer#2:

Singer#3:

Singer#4:

Singer#5:

Pallbearers:

Pallbearer#1:

Pallbearer#2:

Pallbearer#3:

Pallbearer#4:

Pallbearer#5:

Pallbearer#6:

Pallbearer#7:

Pallbearer#8:

Favorite Bible Selections:

Special Services (Military or Lodge)

Cemetery Information

Name of Cemetery:
Location City:
Lot is in the name of:
Section:
Lot:
Grave Space:

Casket and Burial Preferences

Casket:
Metal:
Wood:
Exterior Color:
Interior:
Burial Vault:

Authorized Persons to Arrange Final Details

Person#1 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:

Person#2 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:

Person#3 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:

Person#4 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:

Person#5 Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:

Special Instructions