Riggin-Pillatsch & Burke Funeral Home
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Pre-Planning Form

Please complete the form below. Once it is submitted, a pre-need counselor will follow up with you to answer any questions or concerns you may have.

Please note that there are additonal items to go over when pre-planning a funeral such as: merchandise selection and payment options. We pride ourselves on specialzing in personalization of services; therefore, additional questions may need to be aksed or preference selections gone over.

This on-line form is a beginning step.

If you would rather go over your pre-planning options in person, contact us to set up a time to meet with a pre-need counselor.

I am planning for:
Other:
Personal Information:
Full name:
Sex:
Female
Male
Email address:
Telephone number:
Address:
City:
State:
County:
Zip Code:
Date of Birth:
Place of Birth:
Father's Name:
Mother's Maiden Name:
Social Security Number:
Marital Status:
Spouse's Name:
(Include Maiden Name if applicable)
Date of Marriage:
Place of Marriage:
Spouse's Date of Death:
(If applicable)
Education:
High School
(years completed):
College or Trade School (years completed):
Below please list surviving family members, their relationship to you, their spouses, the current city in which they live, and any family members that are predeceased.
Ex.: Son and daughter-in-law, James & Mary Smith-Anywhere, IL
Survivors:
More Survivors:
Preceded in death by:
Work History:
Occupation:
(Include Job Title, Company and years worked)
Business/Industry:
Below please list any church involvement, civic memberships, lodges, clubs, hobbies, special interests, etc. 
Church Involvements, Clubs, Etc.:
Hobbies/Special Interests:
Military Service: you will need the veteran's DD214 for additional information to order a government marker and/or applicable veteran's benefits.
Branch of Service:
Services Dates:
(Date Inducted to Date Discharged)
War/Military Conflict:
Flag is to be:
I prefer Military Rites to be performed at the cemetery:
No
Yes
Person to receive flag:
Did veteran belong to any Military organizations?:
Funeral Service Preferences:
I prefer:
Other:
Services to be held at:
Private Services
Public Services
Officiant:
Cemetery:
City & State:
Monument Company:
Participating fraternal or service organization: