CONSCIOUS LIVING / PREPARATION FOR DEATH

Essential Information

As a Meeting member or attender you are encouraged to complete this form to provide the Meeting with information that may be useful in the event of an emergency or your death. This information will be kept in a sealed envelope and filed in a locked, fireproof box in the meeting house. Only the Clerk and Convener of Care and Counsel will have access to it. Going through the form may also serve as a check on whether your estate documents are complete, up to date and available if needed. See also the Planning Checklist. If you have questions or wish to discuss any parts of this document, please contact the Clerk or a member of Care and Counsel.

Please type or print clearly

Your Full Name ________________________________________________________

Address: _________________________________________

Telephone # Home_________________ Work_____________________

In the Event of an Emergency or Death

Person to Notify______________________________ Relationship________________

Address_____________________________ Telephone___________________

E mail: ______________________________ Fax: ____________________

Person to Notify______________________________ Relationship________________

Address_____________________________ Telephone___________________

E mail: ______________________________ Fax: _____________________

Person you feel close to in the Meeting_________________________________________

Other local person who knows you well________________________________________

Address: ____________________________________ Telephone ___________________

Others to notify:

Name Relationship Address Phone #

________________________ ________ ______________________________ ______________________

Essential Documents

More about the below documents – purpose, preparation, storage, etc. - can be found in the Personal Inventory and Document Description, available at the Meeting House or at www.rtpnet..org/chfm

Living Will

Have a living will? Yes / No Where stored _________________________________________

Who has copies:

Name: ___________________ telephone: ______________ relationship:____________ (see page 1) ___

Durable Power of Attorney(DPA): Yes / No Health Care Power of Attorney(HCPA): Yes / No

Where stored __________________________________________

Who has copies:

Name: ___________________ telephone: _______________ relationship:____________ (see page 1) ___

Will

Have a will? Yes / No Where stored _______________________________________________

(original should not be kept in a bank box)

Who has copies:

Name: ___________________ telephone: ________________ relationship:____________ (see page 1) ___

Additional information

Person who has additional pertinent information__________________________________________________

Address_____________________________________________________ Telephone__________________

Funeral or Memorial Arrangements

Are you a member of a Memorial Society*? Yes_____ No_____

If yes: Name________________________________________Telephone_________________

Do you have a preference for a funeral home? Yes ____ No ____ Have contract? __________

If yes: Name________________________________________Telephone_________________

What are your wishes for disposition of your remains:

r Medical Research:

Name of Institution_______________________________ Telephone________________

r Organ Donations:

Name of Institution_______________________________ Telephone_________________

r Cremation

Crematory______________________________________ Telephone_________________

Ashes to Meeting’s Memorial Garden: scattered___ buried ___

Other disposal (describe) ______________________________________________

r Burial

Cemetery name__________________________________________________

Location of deed____________________________________________________

What is your preference concerning a service?

r Funeral Service: Meeting for Worship at funeral parlor with ___or without ___ remains present.

r Memorial Meeting: Meeting for Worship at the Meeting house (without remains present).

r Committal Service: A gathering at Memorial Garden, graveside or crematory. May be held by itself or in conjunction with the above.

r No service

Burial Insurance: Agent’s name______________________________Telephone_____________

Address___________________________________________

Location of policy _________________________________________________________

Policy number__________________________

Special Requests for selected service:

Person(s) to plan, open and close service _____________________________________________

Other requests (location, decorations, music, readings, reception, etc.)________________________

________________________________________________________________________________

Information or donations in your memory you would like included in an obituary:

_________________________________________________________________________________

Newspapers/journals to receive your obituary:

_____________________________________________________________________

Required information for North Carolina Certificate of Death

Social Security # ______________________ Date of birth________________________

Birthplace (city and state or foreign country) ___________________________________

Armed Forces: Yes_____ No_____

Marital status: married____ never married_____ widowed_____ divorced_____ other ____

Spouse (if wife, maiden name)___________________________________

Usual occupation (do not use retired)__________________________________________

Kind of business/industry___________________________________________________

Hispanic origin (if yes ___ , specify country)________________________________

Race (circle all that apply): need to add correct categories from certificate

Education (highest grade completed) _________________________________________

Father’s name ___________________________________________________________

First middle last

Mother’s name___________________________________________________________

First middle last

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