Middlebury
Friends Meeting
Statement
of Personal Wishes
& Guidance Upon My Death
Personal
Full Name:
Address:
Telephone # :
Place of Birth: ������������������������������������������������� Date of Birth:
Social Security #�� ������������������������������������������������������� Location of Will:
Executor
of Will:� �������������������������������������������������������� Telephone #
Address
People To Be Notified Immediately by the Passage With Care Committee: Please list key persons who would be willing to notify networks of other people, such as an immediate family member, a professional colleague, a close friend, etc. Also attach a separate list of people to be notified about the memorial service or funeral.
1.��� Name:
Address ���������
Telephone # ��������������������������������������������������� Relationship:
2.��� Name:
Address ���������
Telephone # ��������������������������������������������������� Relationship:
3.��� Name:
Address ���������
Telephone # ��������������������������������������������������� Relationship:
4.��� Name:
Address ���������
Telephone # ��������������������������������������������������� Relationship:
5.��� Name:
Address ���������
Telephone # ��������������������������������������������������� Relationship:
Instructions For Final Arrangements
�
Please consider what your wishes
are for disposal of body or ashes:
Would you prefer burial (what kind
of coffin? A particular cemetery? Embalming? etc.) or cremation (which crematory? Who should transport the body?� What vessel for containment of ashes? Dispersal of ashes?) In
For disposal of my body or ashes I prefer:
Funeral Director: If you wish to have a professional funeral director involved, indicate the name, address and phone number. Have you talked with this funeral director?
Memorial Service or Funeral:� Location?� Someone to officiate? Music? Fowers? Who should be notified, near and far? Do you have any other specific instructions?
Charitable Donations: Please provide Names and addresses of organization(s) you
wish to receive memorial donations in your name:
Name:�
Address:
Name:�
Address:
Name:�
Address:
Obituary: Written by whom (yourself or someone else)?� Where should your obituary be published? Who has information about your life?
Care of Minor Children: Names & phone numbers of those responsible for immediate and long term care of minor children? Other instructions concerning their care?
Name:�
Phone #:
Name:�
Phone #:
Name:�
Phone #:
Other Instructions
Pet Legacy:� Name & phone number of whomever will provide care for your pets
Name:� Phone #: /
Name:� Phone #: /
Quaker Grove: Would you like a tree or bush planted at the
Please give more information if you wish. The more details written down ahead of time, the more easily survivors can act upon your wishes. Do not hesitate to add details and other thoughts to this form or on additional pages. You may
amend this form at any time by replacing it all together with a new form,� or adding dated and signed amendments.
Basic Information Which May Be Needed
Terminal Care Documents (Advance Directives or Living
Will):� Are these current & up to
date?:
Have you filled out a Living Will? Have you discussed your wishes for
end-of-life care? With whom?
Who has any written documents?� (Names
and Phone #)
Where are these documents kept?
Organ Donation:� Since
this needs to be acted on very soon after death, it is helpful that many people
know your wishes ahead of time so those present can act promptly, especially if
your death does not occur in a hospital. Do you wish to donate any of your
organs? Which ones? Have you filled out an Organ Donation card? Where is this
located?
Durable Power of Attorney for Health Care (DPA/HC)?� What is the name, address & phone number of whomever has DPA/HC for you?�
����������� Name:
����������� Address ���������
Telephone #:���������������������������������������������������� Relationship:
Where is this document kept?
Other Legal & Financial Information
(Optional)
Durable Power of Attorney for your Estate:�
Name:
Phone #:
Address:
Bank Accounts:�
Location of bank books, location of banks and phone numbers:
Bank Name�� �������������������������������������������������������������� Account
#
Bank book location�� �������������������������������������������������� Phone
# /
Bank Name�� �������������������������������������������������������������� Account
#
Bank book location�� �������������������������������������������������� Phone
# /
Credit Cards:
Bank Name�� �������������������������������������������������������������� Account
#
Card location�� ������������������������������������������������ Phone # /
Bank Name�� �������������������������������������������������������������� Account
#
Card location�� ������������������������������������������������ Phone # /
Safe Deposit Box:� Location of
box, location of key:
Annuities, Life Insurance Policies:�
Location of these documents; name & phone number of representative
or agent to contact:
Other documents or items that need to be accessed
quickly?