Record of Vital Information

Facts and Preferences at the Time of Death

This form was prepared for your convenience to help provide a single source document of essential personal information and advanced planning data to assist survivors after death occurs. Feel free to PRINT this form and fill it in by hand. Or, you may download the Word document by clicking <here> in order to put your information directly into a Microsoft Word document.

You may wish to complete more than one copy of this form. By all means, a family member or close friend should have a copy. If you think desirable, give your funeral director a copy for his files. Your family or friends should know where you have placed this information. Do not lock the only copy in your safety deposit box.

We suggest you discuss your wishes in detail with your funeral director who will provide careful counseling as a public service, with no obligation.

Prepared in the Public Interest by
Berceuse Funeral And Cremation Traditions
2609 Cunningham Dr.
Hampton, VA 23666
(757) 825-8070

R. Hayden Smith Funeral Home
245 South Armistead Ave.
Hampton, VA 23669
(757) 723 3191

R. Hayden Smith Family Funeral Homes

FIVE GENERATIONS OF OUR FAMILY HAVE BEEN
CARING FOR YOUR FAMILIES FOR OVER 100 YEARS

Date: _____________

Your Phone Number:____________________________

PERSONAL INFORMATION

Name:____________________________

Birth Date:____________________________

Address: ________________________________

City/State _____________________________________

ZIP: _______________

Birth Place: ____________________________

Social Security Number: ____________________________

Education Completed: __________

Year Graduated: _____

Marital Status:____________________________

Spouse’s Name:____________________________

Father’s Name:____________________________

Mother’s Name (Maiden):____________________________
Occupation:____________________________

Date retired (if no longer working):______________________

How Long a Resident:____________________________

Church Membership:____________________________

Veteran of:____________________________

Branch of Service:____________________________

Rank:____________________________

Clubs, Organizations and Other Information
____________________________

____________________________

____________________________

____________________________

____________________________

SURVIVORS

Name	City/State

Spouse____________________________:

Children: ____________________________

Parents:____________________________

Sisters: ____________________________

Brothers:____________________________

Number of Grandchildren:____________________________

Number of Great-Grandchildren:
Other:

SERVICES DESIRED

Place of Funeral Services:____________________________

Place of Burial: ____________________________________

Lot Owner: _________________________

Section and Lot Number: _________

Receive Friends Y/N

Open Casket Y/N

Officiant/Church: ____________________________

Special Music:____________________________

Special Services/Honors:____________________________
Fraternal Rites:____________________________

Newspapers for Obituary:____________________________
Memorials:____________________________

Pallbearers’ Names:


Type of Casket Desired:_________________________

Type of Vault Desired:____________________________
Type of Urn Desired:____________________________

Location of Clothing:____________________________

Flowers or Flag on Casket:____________________________

ADDITIONAL INFORMATION FOR YOUR PERSONAL RECORDS

Name of Attorney:____________________________

Phone:____________________________

Estate Planner:____________________________

Phone:____________________________

Insurance Companies & Policy Number

Military Service:____________________________

Date of Entry:____________________________

Date of Discharge:____________________________

Serial Number____________________________

Location of Discharge:____________________________

You should type or print a letter using the following sample. Remember to sign it and attach the original to this folder and give or send copies to your nearest relative, to your funeral director and attach a copy to your will.

(Date)
To whom it may concern,
I, (your name) of (your address), do hereby express my wishes and requests concerning the disposition of my remains. It is my wish that at the time of my death R. Hayden Smith Funeral Home or Berceuse Cremation and Funeral Traditions be notified, have charge of my remains and arrange for a service and disposition as specified in a document titled “RECORD OF VITAL INFORMATION,” as I have arranged in advance with (name of funeral home). I further request that R. Hayden Smith Funeral Home prepare my remains as is customary for the type of service I desire.

(sign your name)____________________________

(type or print your name)____________________________