Contact and Vital Statistics Information Part 1

First Name:

Middle Name:

Last Name:

Maiden Name:

Nickname:

Street Address:

City:

State / Province:

--- SELECT ONE --- Ohio Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Québec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory

Zip Code:

Country:

--- SELECT ONE --- United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda S. Georgia and S. Sandwich Isls. Saint Kitts & Nevis Saint Lucia Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Somalia South Africa Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands Wallis and Futuna Islands Western Sahara Yemen Yugoslavia (Former) Zaire Zambia Zimbabwe

Phone:

(    )    -   

Email Address:

Vital Statistics Information Part 2

Birth Date:

Month: January February March April May June July August September October November December    Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year: Select one 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Birth Place:

Social Security #:

Marital Status:

--- SELECT ONE --- Married Married but separated Divorced Widowed Never Married

Marriage Date:

Month: January February March April May June July August September October November December    Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year: Select one 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Spouse's Name:

Spouse's Maiden Name:

Father's Name:

Mother's Name:

Mother's Maiden Name:

Next of Kin (emergency contact)

Next of Kin Phone:

( ) -

Race

---SELECT ONE--- White Black or African American American Indian or Alaskan Native (specify tribe) Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian (specify) Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Island (specify) Other (specify)

If Other name here

Education, Occupation and Military

Education:

---SELECT ONE--- 8th grade or less High School but no Diploma High School Diploma or GED Some College but no degree Associates Degree Bachelors Degree Masters Degree Doctorate

Usual Occupation: (cannot use retired)

Industry you were employed in:

Employer Name:

     How long?  

Military Branch:

--- SELECT ONE --- Never Enlisted Air Force Army Marines National Guard Navy

Service Number:

Rank:

Enlistment Date:

Month: January February March April May June July August September October November December    Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year: Select one 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Discharge Date:

Month: January February March April May June July August September October November December    Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year: Select one 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

War Served:

Service Requests

Service Location:

--- SELECT ONE --- Oak Ridge Funeral Care, Winter Haven, FL Oak Ridge Funeral Care, Haines City, FL Church Graveside Other
If Other:

Service Type:

--- SELECT ONE --- Traditional Protestant Service Catholic Mass Rosary Episcopal Service Prayer Service Wake Masonic Eastern Star Jewish Other
If Other:

Military Graveside Service:

Yes No

Service Leader(s):(ie. clergy)

Memorial Contributions:(charity, church,...etc...)

Clothing Requests:

Music Requests:

Flower Requests:

Special Requests:

Disposition Requests

Disposition:

--- SELECT ONE --- Burial Entombment Burial at Sea Cremation Anatomical Donation Removal from State Other

If Burial, Cemetery:

---SELECT CEMETERY--- Auburndale Memorial Park, Auburndale, FL Auburndale Cemetery, Auburndale, FL Bartow Cemetery, Bartow, FL Church of Christ Cemetery, Eagle Lake, FL Evergreen Cemetery, Davenport, FL Florida Natiional Cemetery, Bushnell, FL Forest Hill Cemetery, Haines City, FL Glen Abbey Memorial Gardens, Auburndale, FL Lakeland Memorial Gardens, Lakeland, FL Lakeside Memorial Park, Winter Haven, FL Lakeview Memorial Gardens Oak Hill Burial Park, Lakeland, FL Oak Lawn Cemetery, Winter Haven, FL Rolling Hills Cemetery, Winter Haven, FL Oak Grove Cemetery, Lake Alfred, FL Oak Hill Cemetery, Loughman, FL Trinity Memorial Gardens, Lakeland, FL Other

Most popular cemeteries are listed. We service all cemeteries in the State of Florida.  If not listed type cemetery name here.

Other:

If Cremation,
Disposition of Ashes:

---SELECT ONE--- Burial in Local Cemetery Burial at Florida National Cemetery Family to keep cremated remains Military Burial at Sea Have Family Scatter remains Placement in Niche at Florida National Cemetery Other

Survivor Information for Obituaries

Relationship

Name

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

---SELECT ONE--- Father Mother Wife Husband Son Daughter Brother Sister Grandson Grand-daughter

Number of Great-grandchildren 

Number of Great-Great-grandchildren 

D. Keith Fields, L.F.D.

Copyright © 2005 [Oak Ridge Funeral Care]. All rights reserved.
Revised: 09/26/09