On-line Pre-arrangement Form

There are numerous benefits to pre-arrangement a funeral, some of which include:

Provides peace of mind
Relieves your loved ones of unnecessary concern
Reflects your expressed wishes
Alleviates financial burden on your family

Please take a few minutes to fill out the Online Pre-arrangement form below. Once the information is submitted, a Jamieson & Yannucci Funeral Home representative will review and file it and will be in touch with you to further discuss the details of your arrangements.

If you'd prefer, a printer-friendly version of this form is also available for you to download and fill out manually. CLICK HERE for further instructions and the download link, if interested.

NOTE: Fields marked with an asterisk ( * ) are required. Any information you submit will be held in the strictest confidence - we do not release any information to outside parties under any circumstances.

Information about the Person Completing this Form:
* First Name:
* Last Name:
Middle Name:
* E-mail:
Street Address:
City:
County:
State:
Zip Code:
Phone:
Person for Whom I Am Pre-arrangement:

Vital Information about the Person for Whom Pre-arrangement Is Being Done:
Last Name:
First Name:
Middle Name:
Sex:
Marital Status:
Social Security #:
Date of Birth:	(ex. 1999)
Place of Birth:
Spouse's Full Name:
Spouse's Maiden Name:
Place of Marriage:
Date of Marriage:	(ex. 1999)
Father's Full Name:
Mother's Name:
Mother's Maiden Name:

Work and Education:
Education:
Usual Occupation (most of life):
Kind of Business:
Company:

Military Records:
Branch of Service:
Serial Number:
Date Enlisted:
Rank At Discharge:
Date Discharged:
Discharge On File At:
Copy of Discharge Papers:	Yes No
Name(s) of War(s)/Conflict(s) Toured:

Funeral Service Information:
Place of Service:
Name of Funeral Home:
Address:
Phone:
Place of Visitation:
I Prefer the Funeral Service To Be:
Viewing for Family:	Yes No
Viewing for Friends:	Yes No
Religious Denomination:
Place of Worship:
Lodge / Union:

Person(s) to Finalize Arrangements at Time of Death:
Check here and skip this section if the person filling out this online form is also the person making the final arrangements.

Full Name:
Street Address:
City:
County:
State:
Zip Code:
Phone:

Special Instructions:
Flower Preference:
Music
Casket Bearers (x6):
Jewelry:
Glasses:
Clothing:
Other:

Disposition Options:
I Prefer:
Cemetery:
Address:
Phone:
Section:
I Have Made A Last Will And Testament:	Yes No

Other Information & Instructions:
Please list any other instruction or information you would like us to have:

Memorials & Charities:
Please list any memorials or donations to charity that you would like to declare:

Options:

Please select one of the options below:

Send Information About Pre-arrangement

Contact Me To Set An Appointment

Please Keep My Information On File

Pre-arrangement Form - Printer-friendly Version:

You can download the printer-friendly version of the Pre-arrangement form to your local computer from the link below. Once downloaded, open the PDF *, and enter your information on the form, then print it out on your printer. You may then either mail or fax it to us at the address or fax number below, or bring it with you when you visit.

» CLICK HERE to download the form - choose to, 'Save to Disk,' in the dialog box that appears (download times will vary depending upon connection.)

* NOTE: Adobe Acrobat Reader software is required to view this file - if you don't already have the Reader installed on your computer, it is available for free from Adobe's website - please click the icon at right to be taken to the download page.

Mail completed forms to the following address,
or fax them to the number below:

Jamieson & Yannucci Funeral Home
333 W. High Street
Piqua, Ohio 45356

Fax: 937.778.0119

Please call with any questions: 937-773-3161