Funeral and Interment Instructions of:

Full Name:

  * Required Fields

*

Please Input First Name

*

First Middle Last


1. Immediately after death notify COCHRAN FUNERAL HOME.
 
2. I wish the services to be held at:
3. My Church Affiliation is:
4. I would prefer as clergyman
or:

 


5. My preference of cemetery is::

Special Cemetery Instructions:

 

 

6. I belong to the following organizations:

 

 

and would like

 

to take part in the service.

 

 


 

7. I prefer the following musical selections:

 

Organ:
Vocal:
By:

 

8. I would like the following to act as pallbearers:
1.
2.
3.
4.
5.
6.

9. I have viewed caskets:

 

Yes No

10. I have viewed vaults:

 

Yes No

11. I have provided funds to help defray the cost of my funeral by:

 

 

12.Other instructions or Remarks:

 

 


 

Vital Statistics Record

 

Social Security #:
Marital Status:
Husband / Wife of:
Date of Birth: (format: MM/DD/YYYY)
Birthplace:
Citizen of:
Usual Occupation:

Last Place of Employment / When Retired:

Name of Father:
Mother's Maiden Name:
Residence established here in Hackettstown area:
Coming from:
If Veteran, name of War, Rank, Branchof Service, Years Served, copy of DD214:
Level of Education:

 


 

Surviving Relatives

Relationship Name Address City State

 

Contact Person or Executor is:
Address:
City:
State:
Zip:
Telephone: *

 

security code