120 South Main Street, Winston-Salem, NC 27101
Phone: 336.722.6122   Fax: 336.722.6922

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Pre-Planning Form (Long)


Feel free to leave out any information not marked as required. You may contact a representative of Salem Funerals & Cremations at any time to update this information. If you prefer, a short version of the form is available.

required indicates required field

Information about the person filling out the form:
First Name: required  
Middle Name:    
Last Name: required  
Email: required  
* For your records, the information entered in this form will also be sent to the email address provided above.
Street Address:    
City:    
State:    
ZIP Code:    
Phone:    
Planning for:    
 
Vital information about the person for whom pre-planning is being done:
First Name: required  
Middle Name:    
Last Name: required  
Maiden Name:    
Sex: required  
Marital Status:    
Date of Birth:    
Place of Birth:    
Spouse's Full Name:    
Spouse's Maiden:    
Place of Marriage:    
Date of Marriage:    
Father's Full Name:    
Mother's Full Name:    
Mother's Maiden:    
Work and Education
Education:    
Primary occupation:    
Kind of Business:    
Company:    
Military
Branch of Service:    
Serial No:    
Date Enlisted:    
Rank at Discharge:    
Discharge on file at:    
Discharge papers?    
Name of Wars:    
Funeral Service Information
Place of Service:    
Funeral Home:    
Address:    
Phone:    
Place of Visitation:    
Funeral Service:    
Viewing for Family?    
Viewing for Friends?    
Religious Denomination:    
Place of Worship:    
Lodge/Union:    
Person(s) to Finalize Arrangements at Time of Death
Full Name:    
Street Address:    
City:    
State:    
Zip:    
Phone:    
Special Instructions
Flower Preference:    
Music:    
Casket Bearers (6)
1)    
2)    
3)    
4)    
5)    
6)    
Jewelry:    
Glasses:    
Clothing:    
Other:    
Disposition
I prefer:    
Cemetary:    
Address:    
Phone:    
Last will and testament:    
Other Information and Special Instructions
Other instructions or information:    
Memorials & Charities
List any memorials or donations to charity:    
Contact Options
   
   
   
     
 
 
 
 
 
 
 
 

         

We are not affiliated with Dignity memorial providers or Vogler and Son's Funeral Home located at Reynolda, Clemmons, and Forsyth Memorial Park

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