Pre-Planning: Initial or Update::                                      

        Initial Update

        -- INITIAL: Please complete all that you feel comfortable in forwarding.

        -- UPDATE: Please complete 'Information about person completing form' & First & Last name of the person you are planning for.    The entire form is not required to be completed only the updated, changed or additional information that you are providing.

        -- NOTE: For your protection and ours; All information is verified at time of need with person or persons responsible.

                        Information about the person completing the form::                       

       I am planning for:        Choose One Myself Spouse Mother Father Child Friend Life Partner Other    Other:

                    First Name:      

Middle Name or Initial:    

                    Last Name:    

              e-mail Address:   

              Street Address:   

     City:        State:       Zip:

  Phone:      Work Phone:      Cell Phone:   

                        Vital information about the person you are planning for::                       

This information is required in completing the Death Certificate which is filed with the state registrars office

& the information is also used for newspaper notices.

                                                                                                                       The Blue Highlighted items are only used in the obituary

                                         First Name:       Nick Name: 

                      Middle Name or Initial:    

                                         Last Name:    

                        AKA (Also Known As):    (If Applicable: List any other names that  may have been used legally.  i.e. John J. Doe or J. Doe)

                                                       Sex:    Choose One Female Male     Ever in the Armed Services?:    Yes No Unknown

                       Social Security Number:    (We can obtain this at time of need)

                                        Date of Birth:    Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , (i.e. 1961)

               Place of Birth (City & State):   

Occupation: Please list the occupation that the person you are pre-planning for did most of life.  Do not use retired.

                                           Occupation:        Industry: 

                                      Marital Status:    Choose One Married Never Married Widowed Divorced     If Widowed, Date of Death of Spouse:   

                             Spouse's Full Name:    (If divorced no spouse name required)

Spouse's Maiden Name, if applicable:   

       Place of Marriage (City & State):    (If you wish, used for the obituary only)

                                Date of Marriage:     Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , (i.e. 1985)  (If you wish, used for the obituary only)

                                  Residence-State:      County:

        City:    Street and Number:  (No P.O. Box, Physical Address)

             Residence Inside City Limits:    Yes No Unknown     Zip Code:

                                   Hispanic Origin:    Yes No n/a   If Yes, Please Specify:  (i.e. Cuban, Mexican, Puerto Rican etc.)

                                                    Race:    (i.e. American Indian, Black, White etc.)

   Number of years school completed:    0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17+  

                             Father's Full Name:   

                                 Mother's Full Name:      Maiden Name:   

                       Method of Disposition:    Burial Cremation Removal From State Donation Other Choose One   If Other Please Specify: 

                           Place of Disposition:      (Name of cemetery, crematory or other place)

                     Location of Disposition:    (City or Town and State)

                                                Surviving Relatives                                                      

        Children:  /i.e. First Name (Spouse's Name) Last Name/               Residence:    (City, State)

        Child 1:        Residence Child 1:   

        Child 2:        Residence Child 2:   

        Child 3:        Residence Child 3:   

        Child 4:        Residence Child 4:   

        Child 5:        Residence Child 5:   

        Child 6:        Residence Child 6:   

        If more than 6 children please list in the 'Other Relatives' Text Box

        Siblings: /i.e. First Name (Spouse's Name) Last Name/                   Residence:    (City, State)

        Sibling 1:        Residence Sibling 1:   

        Sibling 2:        Residence Sibling 2:   

        Sibling 3:        Residence Sibling 3:   

        Sibling 4:        Residence Sibling 4:   

        Sibling 5:        Residence Sibling 5:   

        Sibling 6:        Residence Sibling 6:   

        If more than 6 siblings please list in the 'Other Relatives' Text Box

       Grandchildren:  /i.e. First Name (Spouse's Name) Last Name, City, State/ or list a number / or several / or numerous/

        Other Surviving Relatives:

        Preceded In Death By: /i.e. parents, wife, husband, children, brothers & sisters (names may be listed)/

                                                 Education & Work::                                                 

                                     Education:    Primary 0 1 2 3 4 5 6 7 8 9 10 11 12   College 1 2 3 4 5+

                        Schools Attended:    

     Where Worked or Jobs Held:    

                                    Retired in:    (i.e. 1990)

                                                     Military Record::                                                    

    Branch of Service:    Choose One None Army Navy Air Force Marines Coast Guard    If none please skip this section.

         Serial Number:   

          Date Enlisted:    Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , (i.e. 1941)

  Rank at Discharge:   

     Date Discharged:    Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , (i.e. 1946)

Discharge on File at:   

Additional Military Service Information: 

Honorably Discharged Veterans are entitled to a U.S. Flag, Veteran's Grave Marker, and a Burial Space at a National Cemetery for Veteran & Spouse.  We require a copy of the veteran's discharge papers to complete the following:

Desire a Flag for Family:   Yes No n/a   Casket to be Draped:   Yes No n/a

Military Honors:  

Active Duty Honor Guard VFW Group Choose One  Military Honors may be provided by active duty military honor guard from the branch of service the veteran was discharged from, a local V.F.W. group or the Colorado National Guard if no active duty military time was served (the Veterans Administration does not provide a flag for National Guard members with no active duty time, the national guard must provide the flag).

If VFW, Please Specify Group: 

Veterans Grave Marker:  Yes No n/a

National Cemetery:  Ft. Lyon National Cemetery, Las Animas Ft. Logan National Cemetery, Denver Other Please Select a veteran may choose to be buried in a private or city owned cemetery, costs will be incurred by the veteran or the veteran's representative

If Other, Please Specify below in the Funeral / Memorial Service Information section.

Was Veteran Disabled; as Classified by the Veterans Administration:  Yes No n/a

The Veterans Administration Provides Burial Benefits to Disabled Veterans (also includes cremation services).  Please see tab labeled Veterans Services on our web page for additional veteran's benefit information::

                                     Funeral / Memorial Service Information::                               

                  Service Options:    Traditional Burial Service Graveside Burial Service Immediate Burial (no embalming) Traditional Service, Followed with Cremation Visitation, Followed with Cremation, Memorial Service Direct Cremation with a Graveside Service Direct Cremation, No Service Choose One

Place of Service or Church:     

     Religious Denomination:   

           Officiating Minister:   

Visitation/Viewing for Family:    Yes No n/a   Visitation/Viewing for Friends:    Yes No n/a

If applicable; Casket Open or Closed at Funeral Ceremony:   Open Closed n/a

If Traditional Burial or Burial of Cremains; Cemetery:    Choose One Fairview Cemetery Calvary Cemetery East Holbrook Mennonite Cemetery, Cheraw Higbee Cemetery Rocky Ford Cemetery Kim Cemetery Manzanola Cemetery Ordway Cemetery Fowler Cemetery Valley View Cemetery, Sugar City Bent County Cemetery, Las Animas Ft. Lyon National Cemetery Ft. Logan National Cemetery Hasty Cemetery Fairmount Cemetery, Lamar Riverside Cemetery, Lamar Other

If Other Specify Cemetery and City & State:   

Other Service Information that you would like to specify (i.e. Bible passages, Poems, Music, etc.):

If Traditional Burial Service is Requested please Provide Casket Bearers:

                                            1.                       2. 

                                            3.                       4. 

                                            5.                       6. 

                          7. (Optional)      8. (Optional) 

Please List Any Other Information that you would like us to have:

Memorials & Charities (Please list any Memorials or Donations to Charities that you would like):

                                     Please select one of the options below:                                         

          Send information concerning pre-arrangements and services selected

          Contact me to set up an appointment

          Please keep my information on file

At Peacock-Larsen Funeral Home, we take your right to confidentiality very seriously.  We will not share information you submit to us with any person or entity outside of our company not legally entitled to receive it.