SO WE ARE NOT IMMORTAL

[Version of this document in Word]

Instructions for________________ in case of death or possible terminal illness.

1. Vital statistics:

Date of Birth _____________________��

Place of birth _____________________

Father _____________________

Mother _____________________

Church/Meeting membership _____________________

Social Security number _____________________

Medical insurance _____________________
If veteran, Branch, Rank, dates, Serial # _____________________

2. Immediate contacts: (Name, telephone #, address)�

(�� )� Next of kin __________________________________________

(�� )� Friends _____________________________________________________________

�� _______________________________________________________________

(�� )� Physician __________________________________________

(�� )� Attorney __________________________________________

3. in case of terminal illness, Location of:

(�� )� Health proxy __________________________________________

(�� )� Durable Power of Attorney __________________________________________

(�� )� Will. __________________________________________

4. In case of death: Funeral home __________________________________________

5. 1 desire that my body be:

(�� )� Buried in� _____________________Cemetery.

(�� )� Cremated and my ashes

�� (�� )� Buried in�� _____________________Cemetery

�� (�� )� Placed in a columbarium in _____________________��

�� (�� )� Disposed of as follows __________________________________________��

�� ____________________________________________________________

(�� )� Donated to _____________________Medical School for anatomical studies as per previous arrangement (a copy of which is in my personal files)� .

6. I would like to donate organs as per driver's license

(�� )� Eyes to New England Eye Bank (form completed in advance and on file in their office).

(�� )� Other __________________________________________��

7. I desire that there be:

(�� )� An alternative method of treating the body

(�� )� A private service limited to family and close friends

(�� )� A public service

(�� )� Disposal of body as soon as legally possible

(�� )� Closed casket

( ��) �An open casket

(�� )� An inexpensive casket

( ��) �An elaborate casket

(�� )� No display of body

(�� )� No visiting hours

(�� )� An obituary notice at time of death

(�� )� An obituary notice prior to memorial service

(�� )� No obituary notice

(�� )� Other��

8. I wish to have the following:

(�� )� Usual funeral with graveside service

(�� )� Memorial service with private burial before or after

(�� )� My body cremated (with service as indicated above)�

(�� )� Other��

9. I would prefer that instead of sending flowers, my F/friends make memorial gifts, if they wish to __________________________________________

10. Suggestions of material which 1 would like to have used in my service:

(�� )� Scripture passage(s) __________________________________________� ��

(�� )� Favorite appropriate poem(s) _________________________________________ ��

(�� )� Prayers __________________________________________

(�� )� Music __________________________________________

(�� )� Other __________________________________________