House-Rawlings Funeral Home
510 East 4th St.
London, Kentucky 40741
(800) 307-0455
(606) 864-2158

On-line Funeral Pre-arrangement Form


Personal Information

First Name:
Middle Name(s):
Last Name:
Telephone Number:
E-mail Address:
 
 
Address:
Town/City:
State:
Zip Code:
Date of Birth:
Place of Birth:
(city&state or County & state)
Marital Status:
Spouses Name:
(Maiden name and full name of wife or husband’s full name)
Occupation:
(for longest period during working life)
Social Security Number:
Father’s Full Name:
Mother’s Full Name:
(include her madien name)

Person who will be in charge of my funeral arrangements:
Name: 
Address: 
Town/City: 
State: 
Zip Code: 
Telephone Number: 


Military Information
Branch of Service:
Description of Service:
(Wars fought in, medals earned, military campaigns)
Veteran’s Service Number: 
Rank 
Location of Discharge Papers: 


Family Members
Spouse:
(Address and phone numbers)
Daughters:
(Hometowns and phone numbers)
Sons:
(Hometowns and phone pumbers)
Grandchildren:
(Hometowns and phone numbers)
Sisters:
(Hometowns and phone numbers)
Brothers:
(Hometowns and phone numbers)
Other Relatives:
(List relation, hometowns, and phone numbers)


My Funeral Service Preferences
Place of Service:
(Funeral Home, Church, Graveside, or other)
Clergy:
(Minister's hometown and phone number)

Type of Disposition: Burial
Entombment
Cremation
Other (Describe Below)
Cemetery Property Owned? Yes No
Name of Cemetery:
(Include: Location of Cemetery, City, & State)
Cemetery Preference:
(If property not owned, include location of cemetery, city & state)
Music Selections:
(Organ or piano background, live vocal,
or recorded music)
(If live vocal, include the vocalist,
and their phone number)
(List of songs)
Pallbearers or Honorary Pallbearers:
(Include pallbearers hometown, home phone number, and bearer type designation)
(A = Active Bearer, H = Honorary Bearer)

 
Lodge, Society, Fraternal Organization:
(List involvement and if you would
like an honor guard)

Flowers:

Memorial Contributions / Donations:

Obituary Information:

(List education and place of schooling, wedding date and place, work history and places I lived and worked, Clubs, Lodges, Hobbies, what I liked doing, significant accomplishments, Boards, Committees and community and Church involvement, etc.)

Any information or special instructions not previously listed:




Please check as many of the following as apply.
Please contact me so that I may select my casket and vault in advance.
Please forward me a copy of my information for my records.
Please contact me if any of my submitted information needs clarification.
File my information for future reference at House-Rawlings Funeral Home, but please do not contact me.
I would like to discuss my pre-payment options with no obligation, please contact me.


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