Contact and Vital Statistics Information Part 1

First Name:

Middle Name:

Last Name:

Maiden Name:

Nickname:

Street Address:

City:

State / Province:

--- SELECT ONE ---OhioAlabamaAlaskaAlbertaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNewfoundlandNorth CarolinaNorth DakotaNorthwest TerritoriesNova ScotiaNunavutOhioOklahomaOntarioOregonPennsylvaniaPrince Edward IslandQuébecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukon Territory

Zip Code:

Country:

--- SELECT ONE ---United StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaS. Georgia and S. Sandwich Isls.Saint Kitts & NevisSaint LuciaSaint Vincent and The GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSomaliaSouth AfricaSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin IslandsWallis and Futuna IslandsWestern SaharaYemenYugoslavia (Former)ZaireZambiaZimbabwe

Phone:

(    )    -   

Email Address:

Vital Statistics Information Part 2

Birth Date:

Month: JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember   Day: 12345678910111213141516171819202122232425262728293031   Year: Select one19001901190219031904190519061907190819091910191119121913191419151916191719171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005

Birth Place:

Social Security #:

Marital Status:

--- SELECT ONE ---MarriedMarried but separatedDivorcedWidowedNever Married

Marriage Date:

Month: JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember   Day: 12345678910111213141516171819202122232425262728293031   Year: Select one19001901190219031904190519061907190819091910191119121913191419151916191719171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005

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---WhiteBlack or African AmericanAmerican Indian or Alaskan Native (specify tribe)Asian IndianChineseFilipinoJapaneseKoreanVietnameseOther Asian (specify)Native HawaiianGuamanian or ChamorroSamoanOther Pacific Island (specify)Other (specify)

If Other name here

Education, Occupation and Military

Education:

---SELECT ONE---8th grade or lessHigh School but no DiplomaHigh School Diploma or GEDSome College but no degreeAssociates DegreeBachelors DegreeMasters DegreeDoctorate

Usual Occupation: (cannot use retired)

Industry you were employed in:

Employer Name:

     How long?  

Military Branch:

--- SELECT ONE ---Never EnlistedAir ForceArmyMarinesNational GuardNavy

Service Number:

Rank:

Enlistment Date:

Month: JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember   Day: 12345678910111213141516171819202122232425262728293031   Year: Select one19001901190219031904190519061907190819091910191119121913191419151916191719171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005

Discharge Date:

Month: JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember   Day: 12345678910111213141516171819202122232425262728293031   Year: Select one19001901190219031904190519061907190819091910191119121913191419151916191719171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005

War Served:

Service Requests

Service Location:

--- SELECT ONE ---Oak Ridge Funeral Care, Winter Haven, FLOak Ridge Funeral Care, Haines City, FLChurchGravesideOther
If Other:

Service Type:

--- SELECT ONE ---Traditional Protestant ServiceCatholic MassRosaryEpiscopal ServicePrayer ServiceWakeMasonicEastern StarJewishOther
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 ---BurialEntombmentBurial at SeaCremationAnatomical DonationRemoval from StateOther

If Burial, Cemetery:

---SELECT CEMETERY---Auburndale Memorial Park, Auburndale, FLAuburndale Cemetery, Auburndale, FLBartow Cemetery, Bartow, FLChurch of Christ Cemetery, Eagle Lake, FLEvergreen Cemetery, Davenport, FLFlorida Natiional Cemetery, Bushnell, FLForest Hill Cemetery, Haines City, FLGlen Abbey Memorial Gardens, Auburndale, FLLakeland Memorial Gardens, Lakeland, FLLakeside Memorial Park, Winter Haven, FLLakeview Memorial GardensOak Hill Burial Park, Lakeland, FLOak Lawn Cemetery, Winter Haven, FLRolling Hills Cemetery, Winter Haven, FLOak Grove Cemetery, Lake Alfred, FLOak Hill Cemetery, Loughman, FLTrinity Memorial Gardens, Lakeland, FLOther

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 CemeteryBurial at Florida National CemeteryFamily to keep cremated remainsMilitary Burial at SeaHave Family Scatter remainsPlacement in Niche at Florida National CemeteryOther

Survivor Information for Obituaries

Relationship

Name

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-daughter

---SELECT ONE---FatherMotherWifeHusbandSonDaughterBrotherSisterGrandsonGrand-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: 06/05/11