Personal Information
Last Name:
First Name:
Middle Name:
E-mail:
Address:
City:
County:
State:
Zip Code:
Phone:
Vital Statistics
Marital Status:
Never Married
Married
Divorced
Widow
Widower
Social Security#:
Date of Birth:
Place Of Birth:
Spouse's Name:
Spouse's Maiden Name:
Place of Marriage:
Date of Marriage:
Father's Name:
Mother's Name:
Mother's Maiden Name:
Work/Education
Education (0-12):
1
2
3
4
5
6
7
8
9
10
11
12
College 1-5+:
1
2
3
4
5+
Occupation:
Business:
Company:
Military Record
Branch of Service:
Serial Number:
Date Enlisted:
Rank At Discharge:
Date Discharged:
Discharge On File At:
Copy of Discharge Papers:
Yes
No
Name Of Wars:
Funeral Service Info
Place Of Service:
Funeral Home
Church
Cemetery
Funeral Home:
Address:
Phone:
Place of Visitation:
Religious Denomination:
Place Of Worship:
Lodge / Union:
Person in Charge of Final Arrangements:
Special-Instructions
Flower Preference:
Music
Casket Bearers (6):
Jewelry:
Glasses:
Clothing:
Other:
Disposition Request
I Prefer:
Earth Burial
Mausoleum
Cremation
Cemetery:
Address:
Phone:
Section:
Location:
I have made a last will and testament:
Yes
No
Other Instructions
Please list any other instructions you may have:
Memorials / Donations
Please list any Memorials or Donations to Charity that you would like:
Options
Please select one of the options below
:
Send information about pre-arrangement
Contact me to set an appointment
Please keep my information on file
® Bishop & Johnson Funeral Home, Inc.
285 Main St. Hornell NY 14843
(607) 324-2700
Our webmaster:
Mystic Media IT
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