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Worlein Funeral Home Preplanning Form

Please fill out this form and either submit it to us or and mail to:
Worlein Funeral Home- Austin
1801 4th St. NW
Austin, MN 55912
or
Worlein Blooming Prairie Funeral Home
418 Highway Ave. S
Blooming Prairie, MN 55917

Information about person completing the form
I am planning for:
Last Name:
First Name:
Middle Name:
Email:
Street Address:
City:
County:
State:
Zip Code:
Phone:
Vital Information about the person you are planning for
Last Name:
First Name:
Middle Name:
Sex:
Marital Status:
Date Of Birth:
Place of Birth:
Spouse's Full Name:
Maiden Name:
Place of Marriage:
Date of Marriage:
Father's Full Name:
Mother's Name:
Mother's Maiden Name:
Physician:
Facility:
Work and Education
Education:
Usual Occupation (Most of life):
Kind of Business:
Company (Optional):
Military Records
Branch of Service:
Serial Number:
Date Entered:
Rank At Discharge:
Date Discharged:
Discharge On File At:
Copy of Discharge Papers:

Yes  No

Name of Wars:
Funeral Service Information
Place of Service:
Name of Funeral Home:
Address:
Phone:
Place of Visitation:
I Prefer The Funeral Service To Be:
Viewing For Family:
Viewing For Friends:
Religious Denomination:
Place Of Worship:
Lodge / Union:
Person(s) To Finalize Arrangements At Time Of Death

Check here and skip this section if the information is the same as person filling out this form

Full Name:
Street Address:
City:
County:
State:
Zip Code:
Phone:
E-mail:
Family Information
Spouse:
(Name, City, State)
Sons:
(Name, City, State)
Daughters:
(Name, City, State)
Brothers/Sisters:
(Name, City, State)
Number of Grandchildren:
Number of Great-grandchildren:
Special Instructions
Flower Preference:
Music:
Songs:
Obituary Photo:

Yes  No

Funeral Notices to Appear in:
Casket Bearers (6):
Jewelry:
Glasses:
Clothing:
Other:
Disposition Options
I Prefer:
Cemetery:
Address:
Phone:
Section/Lot:
Vault Selection:

Yes  No

Casket Selection:

Yes  No

Other Information & Special Instructions

Please list any other instruction or information you would like us to have:

Memorials & Charities

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

 

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