Vital Statistics

This information will be put on permanent file at the Melvin Funeral Home. A funeral director may call to go over the information, or go over the information that you may not feel comfortable with entering on line.

First Name:
Middle Name:
Last Name:
Maiden Name:
Address:
Phone Number:
Length of Residence:
Sex:	Female Male
Race:
Social Security Number:
Birth Date:	(dd/mm/yyyy)
Birth place(city and state):
U.S. Citizen? Yes No	Marital Status Married Single Divorced Widow Widower
Spouse:
If wife, maiden name:
Schooling: 1 yr 2 yrs 3 yrs 4 yrs 5 yrs 6 yrs 7 yrs 8 yrs 9 yrs 10 yrs 11 yrs 12 yrs	College: 1 yr 2 yrs 3 yrs 4 yrs 5 yrs 5+ yrs
Fathers Name:
Mother's Name:
Mother's Maiden Name:
Retired: Yes No	If Yes, number of years:
Occupation (list occupation before retirement):
Employer:
Employer Address:
Kind of Business/Industry:
Years of Employment:	Veteran of service: Yes No
Serial #
War:
Branch:	Army Navy Marine Corp Air Force
Time of service:	Rank:
Clubs, Organizations, Memberships:
Physician
Surviving Relatives Please List relationship, name, address, and phone (spouse, children, parents, siblings):
Grandchildren:
Great Grandchildren:
Great Great Grandchildren:
Cemetery Information
Do you own burial plots?	Yes No
If yes, where?
If no, what cemetery were you considering?
If yes, what are your burial coordinates listed on your deed?
	If undecided and need more information from our funeral home, please check box.
Briefly describe the type of service that you want, whether a traditional funeral service (with a visitation the night before, or all in the same day, or no visitation), direct cremation, memorial service, or traditional funeral service followed by cremation. If you are unsure, please type in unsure or any preferences that you may have. Please list any other comments or questions that you may have.
Informant Information
Name:
Address:
Phone Number: