Glueckert Funeral Home, Ltd.
1520 N. Arlington Heights Road
Arlington Heights, IL 60004
(847) 253-0168
Funeral Planning Worksheet
Full Legal Name:_______________________________________________________________
Nickname and Also Known As:____________________________________________________
Legal Home Address:____________________________________________________________
Telephone Number:________________________ Mobile Number:________________________
E-mail Address:________________________________________________________________
Date of Birth:__________________________________________________________________
Place of Birth (City, State):________________________________________________________
Father’s Full Name:_____________________________________________________________
Mother’s Full Name include Maiden Name:__________________________________________
Social Security Number:__________________________________________________________
Marital Status: Married Never Married Widowed Divorced
Highest Grade of Education completed:______________________________________________
Did you serve in the US Armed Forces? No Yes
If yes: Branch of Service:_______________ War or Dates of Service:_______________
Occupation (choose only one if varied career):________________________________________
Business or Industry:_____________________________________________________________
Name of Legal Representative or Next-of-Kin:________________________________________
Their Address__________________________________________________________________
Their Telephone Number:_____________________ Mobile Number:______________________
Their relationship:_______________________________________________________________
Physician Name:________________________________________________________________
Physician Address:______________________________________________________________
Physician Telephone Number:_____________________________________________________
Continued
Family
Where appropriate, please use the format: First Name (Spouses First Name) Last Name. List children by age from oldest to youngest. For deceased family members, precede their names by “The Late”
Spouse (include maiden name):____________________________________________________
If Spouse is surviving, Date & place of Marriage:______________________________________
Children (include current home City & State):_________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Grandchilndren:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Siblings:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Background
Employment History (include occupation, job title, company and approximate dates employed):
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
Clubs and organizations (include positions held), honors, awards, noteworthy achievements, interests and other background:____________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
If there is a specific organization, church or charity that you would like memorial contributions to be given list the name, address and telephone number below. Also indicate if you prefer the contributions to be listed “In Lieu of Flowers:”________________________________________
___________________________________________________________________________________________________________________________________________________________.
List the names of all newspapers to which you would like obituaries or death notices to appear:
___________________________________________________________________________________________________________________________________________________________.
If you are a member of a church, congregation or synagogue, list the name, address and telephone number: ______________________________________________________________
_____________________________________________________________________________.
I am not a member of a church, congregation or synagogue, but my background is:
_____________________________________________________________________________.
If you have a clergyperson, list their name, address and telephone number: _________________
_____________________________________________________________________________.
Visitation (Check all that Apply)
_____ I would like a visitation _____ I would like open casket viewing for family
_____ I would like open casket viewing for friends _____ I prefer no visitation
_____ I would like my visitation to be at: Glueckert Funeral Home
or other location _____________________________________________________.
During the visitation, I would like the following:
□ Special Music:________________________________________________________________
□ Photo boards of my life and family □ Memorial video of my life and family
□ Printed goods with Verse:_________________________ Photo_________________________
List any other special requests: ____________________________________________________
___________________________________________________________________________________________________________________________________________________________.
Continued
Funeral Service
I would like my service at: Glueckert Funeral Home
or other location _____________________________________________________.
I would like the following to officiate my service: _________________________________.
For the service I prefer: _____ My casket present _____ My urn present
_____ No casket or urn present
I would like the following readings or verse: _________________________________________
_____________________________________________________________________________.
I would like the following to read the previous: _______________________________________
_____________________________________________________________________________.
I would like the following music: __________________________________________________
_____________________________________________________________________________.
I would like to following to act as pallbearers:
___________________________________ ___________________________________
___________________________________ ___________________________________
___________________________________ ___________________________________
Disposition
I prefer: Ground Burial* Entombment/Mausoleum* Cremation**
*I own property at:___________________________________________________________
and the description is: Section__________, Lot__________, Block__________, Grave________
*I prefer to use (name cemetery or mausoleum):______________________________________.
**I would like my cremated remains (fill in preferred disposition):_______________________
_____________________________________________________________________________.