Submitter Information

First Name

Middle Name

Last Name

Email Address

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Information About The Person For Whom Pre-Planning Is Being Done:

First Name

Middle Name

Last Name

Date of Birth

SexMaleFemale

Spouse's Full Name

Spouse's Maiden Name

Place of Marriage

Date of Marriage

Father's Full Name

Mother's Full Name

Mother's Maiden Name

Work and Education

Education

Usual Occupation (most of life)

Kind of Business

Name of Company

Military Records

Branch of Service

Serial Number

Date Enlisted

Date of Discharge

Rank at Discharge

Location Where Discharge Is On File

Copy of Discharge Papers?YesNo

Names of Wars/Conflicts Toured

Funeral Service Information

Place of Service

Place of Visitation

I Prefer the Funeral Service to BePublicPrivate

Viewing for Family?YesNo

Viewing for Friends?YesNo

Religious Denomination

Place of Worship

Lodge/Union

Person(s) Who Will Finalize Arrangements at Time of Death:

Skip this section if the person filling out this online form is also the person making the final arrangements.

Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email Address

Phone

Special Instructions

Flower Preference

Music

Jewelry

Glasses

Clothing

Other

Names of Six Pall Bearers

Disposition Options

I Prefer

Cemetery

Street Address

City

State/Province

ZIP / Postal Code

Country

Phone

Section

I Have Made A Last Will And TestamentYesNo

Any Other Information And Instructions You Would Like Us To Have:

What Would You Like Us To Do With This Information?Please Send Me Information About Pre-PlanningPlease Contact Me To Set Up An AppointmentPlease Keep This Information On File

Planning Ahead for Your Peace of Mind

Submitter Information

Information About The Person For Whom Pre-Planning Is Being Done:

Work and Education

Military Records

Funeral Service Information

Person(s) Who Will Finalize Arrangements at Time of Death:

Skip this section if the person filling out this online form is also the person making the final arrangements.

Special Instructions

Disposition Options

You may also print this form, fill it out and mail it to: Chiles-Laman Funeral & Cremation Services 1170 Shawnee Road Lima, OH 45805

Let Us Lend a Helping Hand

Shawnee Chapel

Eastside Chapel

Bluffton Chapel