Please fill in the appropriate information and click submit when you are finished, or alternatively, print out this form then bring it to an H.L. Farmer Funeral Home representative. As a helpful suggestion, you may want to make a copy for your records and give a copy to another relative or friend so they are aware of the written information.

              Personal Information

Name:
Gender:	male female
Race:
City:
State:
County:
Zip:
Phone #:
Fax #:
E-Mail:
Social Security#:
Date of Birth:
Place of Birth:
Father's Name:
Father's Birthplace:
Mother's Name:
Mother's Birthplace:
Marital Status:	Single  Married   Divorced  Widowed
Date of Marriage:
Spouse's Name:
Spouse's Maiden Name:
Education & Occupation
Years of Education:
Schools Attended:
Occupation:
Kind of Business or Industry:
Place(s) of Employment:
How Many Years:
Military/Veteran Information
Veteran:
Branch of Service
Serial #:
Served During Wartime:
List War(s)/Conflicts(2)
Date of Enlistment:
Place of Enlistment:
Date of Discharge:
Place of Discharge:
Last Attained Rank:
Organization/Outfit:
Additional Obituary Information:

 

 

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