Funeral planning information sheet

In the interest of privacy, we do not allow you to 'register', partially fill out the form, and then come back online to complete the form. No online/database record is maintained of your responses, and if you decide to not send your responses to us at the end of the process then there is no record being maintained. However, if you don't send in your responses to us, be sure you print out a copy for yourself, otherwise the information will be lost. In either case (sending us your responses online, or not) you can then discuss your requirements with us and we will then be able to refine, suggest, and if you desire, set up an escrowed contract of services.

While some questions seem strange (eg race, ancestry, education level, etc) they will be required for the state death certificate.

Section 1- Identity

This section establishes the identity of the person for whom the arrangements are being made.

These arrangements are for:
Full legal name (first middle last): eg Robert Paul Smith
Commonly used name (eg Bob Smith):
Birth/Maiden name (eg Jane Doe):
Sex:	Male Female Not specified
Usual residence: Address, city of residence, etc..
Date of this form:

Jewish information:
Jewish name (eg Tzvi ben Dovid):
Tribe:	Kohen Levi Yisroel n/a
Father's Jewish name:
Mother's Jewish name:

Vital statistics (all are required on death certificate):
Date of birth (mm/dd/yyyy):
Place of birth (city, state or country):
Father's name (first, middle, last):
Mother's name (first, middle, last, maiden):
Social Security Number:
Highest level of education:	0-6 years 7-12 years High School Diploma Some College Bachelors Degree Masters Degree Doctorate Degree
Usual Occupation:
Kind of business/industry:
Race (eg White, Chinese) :
Ancestry (eg Russian, Polish):
Hispanic Origin:	No Yes

If death has already happened:
Date of Death (mm/dd/yy):
Time of Death:
Age at Death:
Manner of Death:	Natural Accident Suicide Homicide Indeterminate Pending
Death occurred at (eg home, hospital, ambulance, etc):
Death pronounced at eg hospital name and city:
Autopsy performed:	No Yes
Other/Misc:
Who is filling out this form (eg Joe Smith,son):
Other identity comments?

Section 2- Family

This section indicates the family members of the person for whom the arrangements
are being made and is useful for creating the obituary.

Immediate Family History:
Spouse/Companion:
Current 'marital' status:	single married partnered/civil union divorced widowed companion Other
Current partner:
Previous partner(s) (eg deceased spouse):
Children:
Living children (and their spouses) eg George (Brenda) Smith-son:
Deceased children (and their spouses):
Siblings:
Living siblings (and their spouses) eg Bill Smith-brother:
Deceased siblings (and their spouses) eg Sarah (Jim) Jones-sister:
Other immediate family:
Other immediate family members (eg grandparents, grandchilden, step parents):

Other family and friends:
Other family members (eg nephews, cousins, close friends):
Special support (eg caregivers, hospice, medical staff):
Other/Misc:
Other family comments?

Section 3- Activities, Accomplishments

Military Service:
Branch served, final rank:
Veteran Discharge Claim #:
Veteran Organization Affiliations:
Education:
Education- degrees, awards, institutions:
Religious affiliations:
Customary synagogue or place of worship:
Preferred clergy (rabbi, cantor) name, phone:
Religious positions held, organization affiliations:
Professional Life:
Business positions held, organization affiliations:
Business awards, successes:
Other/Misc:
Other activity comments?

Section 4- Funeral arrangements and interment

Body disposition:
Traditional, other:	Traditional Jewish preparation Preparation for repatriation Other (specify in comments)
Casket, burial vessel requests:
Interment details:
Burial at:	cemetery plot mausoleum crypt ashes scattered Other
Burial site if pre-arranged (name, location, plot) or burial site requested:
Special burial instructions eg buried next to wife, military detachment, etc:
Funeral Service Arrangements:
Type (location) of service:	Traditional chapel service in funeral home Graveside service Cemetery chapel service Memorial service
Funeral Service Privacy:	List details on website Do not list service date/time Do not list anything on website
Funeral Home:
Funeral Home Address:
Funeral Home Phone:
Funeral Director:
Names of pallbearers:
Funeral speakers:
Preferred Charities:
Obituary Notices: eg special items to include, which newspapers
Funeral service to be broadcasted?	Yes No Yes with password
Shiva provisions:
Other/Misc:
Other funeral service comments?

Section 5- Administrative

The following are not needed for the funeral home but may be useful to the family:


End of life documents
Living will location:
Last will & testament location:
Executor:
Executor contact info:
Safe deposit info:
List/locations of important papers eg birth/marriage certificates, deeds, titles, policies:
Other/Misc:
Other administrative comments?

If you are interested in discussing this information with us:

If you are going to send this above information to us (online or otherwise), please fill in the information below:

Your name:
Your email (optional):
Do you want us to contact you?	Yes No
How should we contact you and what would be the best time?
Other comments:

If you wish to send the filled out form to us, please also complete the following and then press the "Send Form to The Dorfman Chapel" button below:

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Privacy Information- If you decide to send us, via the "Send Form" button, the information you filled out, we will use this information in order to help you prepare for/arrange a funeral service. The information you send to us will be kept for as long as it takes us to properly respond and/or execute your wishes, and will be used only for that purpose. Unless your request requires a third party consultation, the information will not be shared with others. If you decide not to send us the information you filled out, the information is only retained (temporarily) on the computer you used and should disappear when your browser is closed.
If interested, please see our privacy policy.

30440 W. 12 Mile Rd, Farmington Hills, MI 48334

Phone: 248.406.6000 toll free: 866.406.6003 fax: 248.406.6005