"Serving Androscoggin, Kennebec, Oxford, Lincoln and Cumberland Counties"

Basic Vital Statistic Information

First Name ________________________________
Middle Name ______________________________
Last Name ________________________________
Dr. ______________________________________

Social Security Number ________ - ____ - ________

Date of Birth ______ / ______ / ______

Place of Birth (City and State or Foreign Country) _________________________________________

United States Armed Forces ( for either Spouse) YES NO

Marital Status (Married, Never Married, Widowed, Divorced) _________________________________________

Most Recent Spouse (If wife, give maiden name)
_________________________________________
Are they Living? YES NO

Education (Circle one)

High School - Two years college - Four years + college

What is your usual occupation? (even if retired) _________________________________________

Residence
State________________________________________________
County_______________________________________________
City or Town__________________________________________
Street and Number ____________________________________

Your Parents

Father's

First Name ________________________
Middle Name_______________________
Last Name ________________________

Mother's
First Name ________________________
Middle Name ______________________
Last Name ________________________

--------------------------------------------------------------------------
Contact Person

Mailing Address

_________________________________________
_________________________________________

Telephone Number:
_________________________________________

Funeral Alternatives is an independently owned and operated family company.