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Vital Information
Full Name:
Date of Death:
Address:
Telephone Number:
Email Address:
Date of Birth:
City and Province of Birth:
Father's Name:
Father's City of Residence:
Mother's Name:
Mother's City of Residence:
Mother's Maiden Name:
Spouse's Name:
Spouse's Maiden Name:
Survivors' Names and Cities of Residence:
Relatives Who Have Preceded In Death:
Occupation:
Business Type:
Company Name:
Church Membership:
Lodge or Union Name:
Veteran:
Yes
No
Branch of Service:
Army
Navy
Air Force
Marines
Coast Guard
National Guard
Serial Number:
Date Enlisted:
Date of Discharge:
Rank at Discharge:
Location of a Copy of Discharge (DD214):
Time of Military Service:
Not a Veteran
Peacetime
World War I
World War II
Korean War
Vietnam War
Persian Gulf War
Military Honors at Graveside:
Not a Veteran
Yes
No
Flag Preference for Service:
None
Drape Casket with Flag
Folded Flag on Casket
Type of Service:
Chapel Service
Church
Graveside
None
Visitation Hours:
Day
Night
None
Casket:
Open for Service
Closed for Service
No Public Viewing
Person in Charge of Arrangements:
Officiating Clergy:
Pallbearers:
Flower Preference:
Music Selection:
Jewelry:
No Jewelry
Give to Family
Leave Jewelry On
Glasses:
No Glasses
Donate to Lions Club
Leave On
Give to Family
Casket Preference:
Bronze
Copper
Stainless Steel
Mahogany
Walnut
Cherry
Maple
Poplar
Pine
Fiberboard / Veneer
Minimum Metal
Disposition:
Ground Burial
Mausoleum
Cremation
Outer Container Preference (for ground burial):
Bronze Triune
Copper Triune
Cameo Rose
SST Triune
Veteran
Venetian
Continental
Monticello
Minimum Grave Liner
Cemetery Name:
Cemetery Location:
The Cemetery Property is in the Name of:
Miscellaneous Notes and Instructions:
Please select one of the options below:
Please send me information
Please contact me to schedule an appointment
Please place my information on file
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Bollman's Tribute Center
(503) 623-2325
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287 SW Washington St Dallas, OR 97338
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