A

The following form allows you to record your vital information and be sent to us. Your record will not be shared and will be held securly on file for you and your family when needed. There are no fees for you to record your information with us. Any questions please call us at 319-752-2828 (toll free at 1-877-752-2828). If you would like a printed guide, we would be happy to deliver one to you.

Vital Statistics Information

The following information will be held in strict confidence. Please contact the funeral home with any questions or to recieve a printed copy of this guide.

Vital Statistics Record
Name:*
Age:*
Address:*
State and Zip:*
Phone:*
Social Security No.:
Birthdate:*
City and State of Birth:
Father's Name:*
Mother's Name:*
Spouse's Name (Maiden):
Date of Death if passed:
Date of Marriage:
Where Married:
Spouse's Name (Maiden) if remarried:
Date of Death if passed:
Date of 2nd Marriage:
Where Married:

Personal History
Military War(s):
Branch:
Rank:
Service Dates:
Service Number:
Honors/Commedations:
Location of Discharge Papers:
Education:
Graduated:
Usual Occupation:
Employer:
Number of Years:
Retired:
Church Affiliation:
Organizations / Lodges:
Personal Biographical Information:

The Hass-Thielen Funeral Home will notify The Hawkeye and KBUR.
Other newspapers or radio stations:
Photograph in newspaper:

Immediate Family
Spouse:
City, State:
Number of Son(s):
List Son(s) Name, City, State:
Number of Daughter(s):
List Daughter(s) Name, City, State:
Number of Grandchildren:
Number of Great Grandchildren:
Number of Great Great Grandchildren:
Number of Brother(s):
List Brothers(s) Name, City, State:
List Sister(s) Name, City, State:
List Sister(s) Name, City, State:
Nices and Nephews:
Preceded by:

Local Emergency Contacts (optional)
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:

Important Legal Information for family use (optional)
Will:
Attourney who wrote will:
Executor of estate:
Address:
Safety deposit box at:
Key location:
Instructions where accounts are held:
Insurance (Company name(s) and Policy #'s):

Funeral Service: Instructions & Information
Funeral Home of Choice:
Type of Service:
Casket/Urn Preference:
Outer Burlial Container Preference:
Service at:
Cemetery:
Location:
Section / Block:
Lot:
Space:
Marker Installed?:
Clergy or current clergy at church:
Organist:
Soloist:
Music Selections:
Favorite Bible passages, Poetry, Quotations, Versus, Etc.:
Flowers:
Clothing: New:
Present:
Color:
Hairdresser:
Hairstyle:
Glasses:
Jewelry to be worn for viewing:
If Jewelry should be removed after viewing, whom should it be given to?:
Decision of Jewley and clothing to be made by:
Participating Organizations (Fraternal/Military Honors):
I wish to have my family selesct pallbearers:
Pallbearers (Suggestions):
Alternates/Honorary Pallbearers:
Memorial(s):

Authorization

I have given the preceding information knowing that, at the time of my death, it will be easier for my family if they know of my funeral wishes. I desire that my services, as outlined herin, be handled by the Hass-Thielen Funeral Home.