Glueckert Funeral Home | Arlington Hts, IL

Information on Person for Whom Plans Are Being Made

Full Legal Name *

Title:

First Name:

Middle Name:

Last Name:

Suffix:

Nickname and Also Known As:

Legal Home Address *

Street Address:

City:

State:

Postal / Zip Code:

Country:

Date of Birth *

Place of Birth (City, State) *

Father's Full Name:

Title:

First Name:

Middle Name:

Last Name:

Suffix:

Mother's Full Name:

Title:

First Name:

Middle Name:

Last Name:

Suffix:

Marital Status

Married
Never Married
Single
Widowed

Highest Grade of Education Completed

Serve in the US Armed Forces?

Yes
No

Occupation (choose only one if varied career)

Business or Industry

Next of Kin and Contact

Name of Legal Representative or Next-of-Kin

First Name:

Last Name:

Their Relationship

Their Address

Same Address

Street Address:

City:

State:

Postal / Zip Code:

Country:

Phone:

Physician Name

First Name:

Last Name:

Physician Address

Street Address:

City:

State:

Postal / Zip Code:

Country:

Physician Phone:

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)

Spouse's Address

Same as Above

Street Address:

City:

State:

Postal / Zip Code:

Country:

Spouse's Telephone Number:

Children (include spouse in parenthesis, current home town and any contact information you feel would be helpful)

Grandchildren

Siblings

Background

Submitted by

Submitted by: *

First Name:

Last Name:

Telephone Number *

Additional Contact Options:

Please have a Funeral Director call me
Please have a Funeral Director text me

Online Pre-Planning Form

Please fill out the information below and press "submit" to forward it to our funeral home.

Information on Person for Whom Plans Are Being Made

Next of Kin and Contact

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”

Background

Disposition

Submitted by