Fratzke & Jensen Funeral Home

Your name:

Phone:

Email:

Decedent

First Name:

Middle Name:

Last Name:

Date of Birth:

Place of Birth:

Early Years

Parent's Names:

Mother’s maiden name:

Childhood Hometown:

Education

Grade School:
(name & location)

High School:
(name, location, grad year)

College:
(name, location, degree,
grad year, etc.)

Marriage

Spouse’s Name:
(include a wife’s maiden name)

Date and Place of Marriage:

Religious Affiliation

Current Church:
(name & location)

Baptized:
(date and name/location
of church if possible)

Confirmed:
(date and name/location
of church if possible)

Offices held/
Memberships in church:

Personal Information

Occupation:

Date of retirement:

Hobbies / Personal interests:

Special memories:

Additional Life Information:

Armed Service Information

War and Units served with:

Date entered service:

Special honors:

Date discharged:

Survivors
(Names and City/State
where possible)

Spouse:

Parents:

Sons:

Daughters:

Brothers:

Sisters:

Grandchildren:

Great-grandchildren:

Other:

Preceded in death

Names & relation:

Funeral Planning

Cemetery:
(include location, city and state)

Ceremony:
(church or funeral home)

Please provide names, telephone, email or
other contact information for the people below

Contact Person for Family:

Clergy:

Casketbearers:

Honorary Casketbearers:

Organist:

Singer:

Songs:
(note for soloist
or for congregational hymns)

Flower committee:
(if desired)

Preferred flower shop:

Luncheon:
(where and by whom)

Memorial fund established:
(list address funds to be sent to)

Newspapers for obituary to be sent:
(note with or without photo for each)

Radio stations
to carry service information:

Do you wish to have us call you to
set an appointment to discuss any
further details in person?

Yes No

Do you wish us to put this
information on file as it is recorded
here without a personal visit?

Yes No