Victory Funeral Services - Providing heartfelt services with dignity

Funeral Pre-Planning Form

This Funeral Pre-Planner Form allows you to submit your information directly to Victory Funeral Services to be held in our files until your time of need. Sharing this information with the person that will be the responsible party at the time of your demise would be beneficial. Make sure they have your social security number as well if you choose not to leave it here.
All fields are optional.
Date:
Name (first, middle and last; AKA's if any):
Maiden Name:
Sex:
Female
Male
Date of Birth:
Social Security Number:
Driver's License Number:
Marital Status:
Married
Never Married
Divorced
Widowed
Unknown
Address:
City:
State and Zip Code:
Inside City Limits?:
Yes
No
Home Phone:
Cell Phone Number:
Fax Phone Number:
Birthplace (city and state or foreign country; not county):
Surviving Spouse (if wife, give name prior to first marriage)
Father's Name (first, middle, last)
Mother's Maiden Name:
Education (check box that best describes highest degree or level of school)
8th grade or less
9th - 12th grade, no diploma
High school graduate or GED completed
Some college credit, but no degree
Associate degree (e.g., AA, AS)
Bachelor's degree (e.g., BA, AB, BS)
Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA)
Doctorate (e.g. PhD, EdD or MD, DDS, DVM, LLB, JD)
Race:
Black or African American
White
Hispanic Origin
American Indian or Alaska Native
Chinese
Asian Indian
Other
Ever a peace officer in Texas?:
Yes
No
Usual occupation (indicate type work during working life; do not use retired:
Type of Business/Industry:
Ever in the U. S. Armed Forces?:
Yes
No
Name of organization in which service was rendered:
Army
Navy
Air Force
Marines
Coast Guard
Army National Guard
Army Reserve
Marine Corps Forces Reserv
Navy Reserve
Air National Guard
Air Force Reserve
Coast Guard Reserve
Serial number of discharge papers or adjusted service certificate:
Name of next of kin or next friend:
Address:
Date Entered Service:
Place Entered Service:
Grade or Rank:
Company, Regiment or Division:
Name of War or Conflict:
Date of Discharge:
Place of Discharge:
Decorations:
Special Instructions:
Medal of Honor Recipient:
Yes
No
Flag should be given to:
Veterans Cemetery Marker:
Marble Upright
Marble Flat
Granite Upright
Granite Flat
Bronze Flat
Continue to the next page of this form to finalize your wishes.
Victory Funeral Services, 1004 Martin Luther King Drive, Kilgore, TX 75662 - 903-988-1122 phone  903-234-0511 fax -- dparline@sbcglobal.net