Your Full Name (first, middle, last):
Maiden Name:
Your Email Address:
Mailing Address:
Date of Birth:
Place of Birth:
Social Security Number:
Your Occupation:
Current Employer:
Employer's Address &
Phone Number:
Religious Affiliation:
Place of Worship:
Organization Memberships:
Education (list schools attended and dates of
any degrees or honors received)
Are you an Organ Donor?
Marital Status:
Date of Current Marriage (if applicable):
Place of Current Marriage (if applicable):
Names of Previous Spouses (if applicable):
Father's Name (first, middle, last):
Father's Address (if living):
Mother's Name (first, middle, maiden):
Mother's Address (if living):
Children's Names (if applicable):
Children's Addresses & Phone
(if applicable):
Grandparents' Names:
Great-Grandparents' Names:
# of Grandchildren (if applicable):
# of Great-Grandchildren (if applicable):
# of Great-Great-Grandchildren (if applicable):
Brothers' & Sisters' Names (if applicable):
Brothers' & Sisters' Addresses & Phone
(if applicable):
Names of Other Friends & Relatives
who should be Notified:
Addresses & Phone Numbers for
Other Friends & Relatives:
Names of newspapers for obituary:
Funeral Officiant:
Funeral Service Location:
Visitation Instructions:
Music, hymns or readings you would
prefer during your service:
Organization for memorial in your memory:
Names and Addresses and Phone
Numbers of casket bearers:
Cemetery Name:
Address and Location of
Cemetery Property
Casket preference:
Vault preference:
Disposition preference:
Location of will:
Location of advance directive/living will:
Name of the Executor of your Estate:
Address & Phone Number of
your Executor:
Location of Safety Deposit Box & Key:
Attorney's Name:
Address & Phone Number of
your Attorney:
Primary Physician's Name:
Address & Phone Number of
your Primary Physician:
Location of Checking Accounts,
Checkbooks, Savings Accounts,
Investments, etc.:
Insurance Companies and
Policy Numbers:
Location of Insurance Policies:
Any Additional Instructions:
Are you a U.S. Veteran?
Branch of Service:
Date of Enlistment:
Place of Enlistment:
Date of Discharge:
Place of Discharge:
Service Numbers:
Organization or Outfit:
Commendations Received:
Location of Discharge Papers:
Flag Desired to Drape Casket:
How do you wish us to process your information? (Check all that apply.)
Call me.
Email me.
Send me information via mail.
Keep my information on file.
Stockdale-Moody Funeral Services
2898 West Walnut, Rogers, Arkansas 72756

Since 1960, the number of pre-planned funerals has increased by 1000%. Why such a dramatic
increase in Pre-Planned Funerals?
Because pre-planning guarantees:
•        Your wishes will be fulfilled.
•        You will spare your loved ones any unnecessary financial burden.
Pre-planning your own funeral makes sense because it allows you to take full control of your
funeral right now. You can save your loved ones the trauma of making difficult decisions without
knowing exactly what you have wanted.
Pre-planning allows you to confer with your loved ones and make your plans together, thus
resolving your most personal matters with a clear mind, in a peaceful and relaxed atmosphere. In
return, you will save the people you care about most from the emotional turmoil and burdensome
decisions that an unplanned funeral can often bring.
By making the decision to pre-pay now, you will lock in the cost of your funeral at today's prices,
even if you live for another 50 years. When you pre-arrange and pre-pay, you can be assured that
definite arrangements have been made and no other financial decisions need to be faced. No
matter what the cost of fulfilling your last wishes at your time of need, pre-payment guarantees
the cost will remain constant, regardless of inflation. In fact, since pre-paying ensures that you are
protected against inflation, you can save thousands of dollars to spend as you please or leave to
your loved ones by making the decision to pre-pay.
We Honor All Standard Burial Policies & Pre-Arranged
Funeral Plans, Complete Pre-Arrangements & Insurance Plans
Available, Complete Pre-Arrangement & Insurance Plans