CRITICAL INFORMATION
(The following pages are made available for you to assist and advise your family of
your desires and other information after your death.)
Name: _______________________________________________________________________________
Address: _____________________________________________________________________________
Phone #: ______________________________ Cell Phone #: ___________________________________
Social Security Number: ______-______-______
Date of Birth: _______________ Place of birth: ______________________________________________
Marital Status: Married _____ Date: _____________ Never Married ____ Widowed ____ Divorced ____
Name of Surviving Spouse: ______________________________________________________________
(Maiden name if wife)
Occupation: __________________________________________________________________________
Employer: ____________________________________________________________________________
Father’s Name: ________________________________________________________________________
Place of Birth: __________________________________________
Mother’s Name: _______________________________________________________________________
Place of Birth: __________________________________________
Person in charge of Arrangements: ________________________________________________________
Phone Number: _________________________________________________________________
MILITARY SERVICE
Branch of Service: ______________________________________________________________________
Service Serial Number: _________________________________
Date of Entry: ________________________________________
Place: ______________________________________________
Discharge of Service: __________________________________ Place of Discharge: _________________
Date: _______________________________
Highest Grade, Rank, Achieved: __________________________________________________________
Wars/Conflicts Served: _________________________________________________________________
Additional Information:
Medals: _________________________________________________________________
Honors: ________________________________________________________________
Citations: _______________________________________________________________
FUNERAL SERVICE WISHES
Funeral Home: ________________________________________________________________________
Address: __________________________________________ Phone #: ___________________________
Place of Service: _______________________________________________________________________
Church Name
Parish Name
Type of Service (circle one): Funeral Mass (greatly encouraged – please see Guidelines #3)
Funeral Home Service
Committal (Graveside Service)
Memorial donations may be made to: _____________________________________________________
Floral Preference (type and color): _________________________________________________________
Full Burial or Cremation: ________________________________________________________________
Full Burial Preferences:
Type of casket (circle one): Wood
Metal
Other: _______________________
Casket during Wake: Open ____ Closed ____
Cremation Preferences:
Type of urn (circle one): Wood
Bronze
Marble
Other: ________________
Body Present at Mass? Yes ____ No ____
Visitation: Public ____ Private ____ None ____
Rosary Said: Yes ____ No ____
Participating Organizations at Wake or Committal Service (military, fraternal, lodge, etc.): __________
_____________________________________________________________________________________
Flag (Committal Service Only): Draped ____
Folded _____
Presented to: _____________________
Clothing preference: From Current Wardrobe ____ New ____ Other: ____________________________
Description/Color: _______________________________________________________________
Personal Accessories:
Wedding Band: Stays On ____ or Returned to: ________________________________________
Eyeglasses: Stays On ____ or Returned to: ____________________________________________
Other: ______________ Stays On ____ or Returned to: _________________________________
FUNERAL MASS INFORMATION
Music Selections (See Attached List):
Opening: _____________________________________________________________________________
Offertory: ____________________________________________________________________________
Communion: __________________________________________________________________________
Closing: ______________________________________________________________________________
Liturgy of the Word (See Attached List):
First Reading (Old Testament): ________________________________ Reader: ____________________
Second Reading (New Testament): ____________________________ Reader: _____________________
Pallbearers
Name
Relationship
Phone #
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
CEMETERY INFORMATION
Cemetery: ____________________________________________________________________________
City: __________________________________________________________________________
If owned, name of Burial Right Holder is/are: _______________________________________________
Description: Lot Number: ________ Section: ________ Row: ________ Block: _________
Memorialization
Upright Monument _____ Flush granite _____ Flush bronze _____ Other: _________________________
Inscription: ___________________________________________________________________________
Emblem(s): ___________________________________________________________________________
The cemetery management must certify the type of memorial chosen is acceptable.
Opening and Closing or Entombment Fees: Prepaid _____ To be determined _____
Cremation
If cremation what type of disposition? Burial_____ Niche _____
Cremation Vault?: Yes_____ No _____ (Vaults may be required by the cemetery)
When contemplating your final resting place, be sure to have clear entitlement to the burial rights for the
lot or grave space you wish to use. If the burial rights were originally purchased by a parent or
grandparent, rights may be shared equally by siblings or cousins. Possession of the Easement or verbal
agreement does not constitute ownership. A simple call or visit to the cemetery sexton can put your mind
at ease and prevent any complications for your loved ones.
FAMILY INFORMATION
Information for: _______________________________________________________________________
Name: _______________________________________________________________________________
Relationship: __________________________________________________________________________
Phone Number: ________________________________________________________________________
Address: _____________________________________________________________________________
Email: _______________________________________________________________________________
Name: _______________________________________________________________________________
Relationship: __________________________________________________________________________
Phone Number: ________________________________________________________________________
Address: _____________________________________________________________________________
Email: _______________________________________________________________________________
Name: _______________________________________________________________________________
Relationship: __________________________________________________________________________
Phone Number: ________________________________________________________________________
Address: _____________________________________________________________________________
Email: _______________________________________________________________________________
Name: _______________________________________________________________________________
Relationship: __________________________________________________________________________
Phone Number: ________________________________________________________________________
Address: _____________________________________________________________________________
Email: _______________________________________________________________________________
Name: _______________________________________________________________________________
Relationship: __________________________________________________________________________
Phone Number: ________________________________________________________________________
Address: _____________________________________________________________________________
Email: _______________________________________________________________________________
NOTIFICATIONS
FAMILY
Name: _______________________________________________________________________________
Relationship: __________________________ Phone Number: ___________________________
Name: _______________________________________________________________________________
Relationship: __________________________ Phone Number: ___________________________
Name: _______________________________________________________________________________
Relationship: __________________________ Phone Number: ___________________________
Name: _______________________________________________________________________________
Relationship: __________________________ Phone Number: ___________________________
Name: _______________________________________________________________________________
Relationship: __________________________ Phone Number: ___________________________
CO-WORKERS
Name: _______________________________________________________________________________
Company: _____________________________ Phone Number: ___________________________
Name: _______________________________________________________________________________
Company: _____________________________ Phone Number: ___________________________
Name: _______________________________________________________________________________
Company: _____________________________ Phone Number: ___________________________
Name: _______________________________________________________________________________
Company: _____________________________ Phone Number: ___________________________
Name: _______________________________________________________________________________
Company: _____________________________ Phone Number: ___________________________
MEMBERSHIPS
Name of Organization: __________________________________________________________________
Contact Person: ___________________________ Phone Number: ________________________
Name of Organization: __________________________________________________________________
Contact Person: ___________________________ Phone Number: ________________________
Name of Organization: __________________________________________________________________
Contact Person: ___________________________ Phone Number: ________________________
Name of Organization: __________________________________________________________________
Contact Person: ___________________________ Phone Number: ________________________
Name of Organization: __________________________________________________________________
Contact Person: ___________________________ Phone Number: ________________________
WILL INFORMATION
A will is important. No matter how large or small your estate if you die without a Will the state and the
courts will decide who will administer your estate, handle your finances and care for your minor
children.
With a proper will, you decide. Joint ownership of property is not a good substitute for a carefully
written Will. The law is very particular with respect to properly executed Wills. A do-it-yourself will may
not hold up in court. It is prudent to review your will whenever your family situation changes. Laws vary
from state to state with respect to children born after your Will was executed. Protecting your family
and your property with a carefully executed will is well worth the attorney’s fee.
I have a Will: Yes_____ No _____
Date of Will: ________________________________ Location of Will: ____________________________
Representative:
Name: _____________________________________ Relationship: _______________________________
Address: _____________________________________________________________________________
Phone Number: ________________________________________________________________________
Law Firm: _____________________________________________________________________________
Name of Attorney: _____________________________________________________________________
Address: _____________________________________________________________________________
Phone Number: ________________________________________________________________________
PLANNED GIVING
Please remember to prayerfully consider your family parish in your estate planning. Your bequest can be
a lasting legacy for what you consider most important. Please further the mission of the Church through
a gift that makes an impact for the good. The Parish Educational Endowment Trust Fund is one example
of a wonderful way to support the work of catechesis. Please contact the parish office at 608.372.4516
with any questions.
FINANCES
Bank/Credit Union Accounts
Name: ____________________________________ City: _______________________________________
Type of Account: _________________________ Account Number: ________________________
Name: ____________________________________ City: _______________________________________
Type of Account: _________________________ Account Number: ________________________
Name: ____________________________________ City: _______________________________________
Type of Account: _________________________ Account Number: ________________________
Name: ____________________________________ City: _______________________________________
Type of Account: _________________________ Account Number: ________________________
Name: ____________________________________ City: _______________________________________
Type of Account: _________________________ Account Number: ________________________
Safe Deposit Box
Name of Bank: ____________________________________ Box Number: _________________________
Location of Keys: ____________________________ Person(s) with Access: _________________
Name of Bank: ____________________________________ Box Number: _________________________
Location of Keys: ____________________________ Person(s) with Access: _________________
Debts (Mortgages, Loans, Charge Accounts and Credit Card Accounts)
Name of Company: _____________________________________________________________________
Account Number: ___________________________ Type of Account: ______________________
Name of Company: _____________________________________________________________________
Account Number: ___________________________ Type of Account: ______________________
Name of Company: _____________________________________________________________________
Account Number: ___________________________ Type of Account: ______________________
Name of Company: _____________________________________________________________________
Account Number: ___________________________ Type of Account: ______________________
Name of Company: _____________________________________________________________________
Account Number: ___________________________ Type of Account: ______________________
Name of Company: _____________________________________________________________________
Account Number: ___________________________ Type of Account: ______________________
Name of Company: _____________________________________________________________________
Account Number: ___________________________ Type of Account: ______________________
INSURANCES
Company Name: ______________________________________ Agency: __________________________
Type: ______________________________________ Policy Number: ______________________
Company Name: ______________________________________ Agency: __________________________
Type: ______________________________________ Policy Number: ______________________
Company Name: ______________________________________ Agency: __________________________
Type: ______________________________________ Policy Number: ______________________
Company Name: ______________________________________ Agency: __________________________
Type: ______________________________________ Policy Number: ______________________
Company Name: ______________________________________ Agency: __________________________
Type: ______________________________________ Policy Number: ______________________
PENSIONS
Source of Income: _______________ Monthly Payment: ____________ Death Benefit: ______________
Source of Income: _______________ Monthly Payment: ____________ Death Benefit: ______________
Source of Income: _______________ Monthly Payment: ____________ Death Benefit: ______________
Source of Income: _______________ Monthly Payment: ____________ Death Benefit: ______________
MUTUAL FUNDS, STOCKS, BONDS
Company or Investment: ____________________________ Type of Fund: ________________________
Location of Certificate, Statement or Portfolio: ____________________ Policy Number: _____________
Company or Investment: ____________________________ Type of Fund: ________________________
Location of Certificate, Statement or Portfolio: ____________________ Policy Number: _____________
Company or Investment: ____________________________ Type of Fund: ________________________
Location of Certificate, Statement or Portfolio: ____________________ Policy Number: _____________
REAL ESTATE
Location of Deed: ______________________________________________________________________
Address: _____________________________________________________________________________
Description: __________________________________________________________________________
Location of Deed: ______________________________________________________________________
Address: _____________________________________________________________________________
Description: __________________________________________________________________________
Location of Deed: ______________________________________________________________________
Address: _____________________________________________________________________________
Description: __________________________________________________________________________
Location of Deed: ______________________________________________________________________
Address: _____________________________________________________________________________
Description: __________________________________________________________________________
LOCATION OF DOCUMENTS
Indicate on the lines the location of various important papers by inserting the following letters:
H (Home) S (Safe Deposit Box) W (Work) A (Attorney) C (Computer Storage) O (Other)
Wills ____
Health Insurance Policy ____
Living Will ____
Automobile Title or Bill of Sale ____
Birth Certificates ____
Home Owners Insurance ____
Military Discharge Papers ____
Certificate of Burial Rights (Cemetery grave
Marriage License ____
Space) ____
Copy of Mortgage or Lease ____
Automobile Insurance ____
Life Insurance Policies ____
Tax Returns ____
Deeds ____
Citizenship Papers, if applicable ____
Passwords ____
MEDICAL HISTORY INFORMATION
Certain medical conditions may be hereditary; the following information may be helpful to your children
and grandchildren.
I have received treatment for:
___ High Blood Pressure: __________________________________________________________
___ High Cholesterol: ____________________________________________________________
___ Diabetes: ___________________________________________________________________
___ Cancer: ____________________________________________________________________
___ Heart Disease: _______________________________________________________________
___ Kidney Disorder: _____________________________________________________________
___ Glaucoma: __________________________________________________________________
___ Macular Degeneration: ________________________________________________________
___ Other: _____________________________________________________________________
___ Other: _____________________________________________________________________
___ Other: _____________________________________________________________________
I am allergic to the following drugs:
a) _____________________________________ b) _____________________________________
c) _____________________________________ d)_____________________________________
Physician: __________________________________ Phone Number: _____________________________
Hospital/Clinic: __________________________________________________________________
I am an Organ Donor: Yes ____ No ____
I am leaving my body to Science: Yes ____ No ____
BIOGRAPHICAL INFORMATION
An obituary is important and meaningful to those loved ones left behind. Include information about
your education, work, accomplishments, etc.
Place of birth and early years of childhood: __________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Schools: ______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Work Information: _____________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Member Organizations: _________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Parish Name: __________________________________________________________________________
Parish Committees, Activities, etc.: ________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Achievements & Special Honors: __________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Notes: _______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________