Kelly Funeral Home 154 Lincoln Street Worcester, MA 01605 800-660-4507 Fax: 508-755-0990

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Please complete the following form to begin the pre-planning process.

Personal Information

Name :
Marital Status:	Never Married Married Divorced Widow Widower
Date of Birth:		Place Of Birth :
Address:
City:		State:
County:		Zip:
Phone:		E-mail:
Spouse's Name:		Spouse's Maiden Name:
Place of Marriage:		Date of Marriage:
Father's Name:		Mother's Name:
Place Of Birth :		Place Of Birth :
Mother's Maiden Name:
Social Security #

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Work/Education History

Education(0-12):		College 1-5+:
Occupation:
Business:		Company:

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Military Record

Branch of Service:		Serial Number:
Date Enlisted:		Rank At Discharge:
Date Discharged:		Discharge On File At:
Do you have a Copy of Discharge Papers:     Yes     No
Name Of Wars:

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Funeral Service Request

Place Of Service: Funeral Home Church Cemetery
Place of Visitation:
Religious Denomination:
Place Of Worship:
Lodge / Union:
Person in Charge of Final Arrangements:

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Special Instructions

Flower Preference:
Music:
Jewelry:
Glasses:
Clothing:
Other:

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Disposition Request

I Prefer:	Earth Burial Mausoleum Cremation
Cemetery:
Address:		Phone:
Section:
I have made a last will and testament:     Yes     No
Location:

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Other Instructions

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Memorials/Donations To Charity

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Please select one of the options below

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E-mail us: info@kellyfuneralhome.com

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