Pre-planning Form

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If you'd prefer a printer-friendly version of this form CLICK HERE and download to your computer and fill out.

If you have any questions whatsoever, please contact us.

Information about the person completing this form

I am planning for

Last Name *

First Name *

Middle

Street Address

City

State

Zip

County

Phone *

E-mail

Information about the person you are planning for

Last Name

First Name

Middle

Gender

Marital Status

Date of Birth

Place of Birth

Spouse’s Full Name

Spouse’s Maiden Name

Place of Marriage

Date of Marriage

Mother’s Name

Mother’s Maiden Name

Father’s Name

Work and Education

Education (Primary)

College (1-5+)

Usual Occupation (most of life)

Kind of Business

Company

Military Records

Branch of Service

Serial Number

Date Enlisted

Rank at Discharge

Date Discharged

Discharge on file at

Copy of Discharge

Yes

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 of Family

Yes

Viewing of Friends

Yes

Religious Denomination

Place of Worship

Lodge/Union

Person(s) to Finalize Arragements at Time of Death

Full Name

Street Address

City

State

Zip

Phone

Special Instructions

Flower Preference

Music

Casket Bearers (6)

Jewelry

Glasses

Clothing

Other

Disposition Options

I prefer

Cemetery

Address

Phone

Section

I have made a last will and testament

Other Information and Special Instructions

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

Memorials and Charities

Please list any Memorials or Donations to Charity that you would like

Contact Options

Send information about pre-arrangement

Contact me to set an appointment

Please keep my information on file

Locally owned funeral and cremation services Half Moon Bay, Funeral Director, estate planning, pre need funeral counselors

Meet Our Manager

Greg Miller

For 30 of Greg’s 37 years as a funeral director he’s been helping families at Miller-Dutra Coastside Chapel... More

Thank you for your wonderful help and great efficiency. It is a pleasure to work with you.

— Wendy L.

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Miller-Dutra Coastside Chapel

650-726-4474

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