Obituary Form

* Indicates required field

Your Name *

First

Last

Your Email *

Your Phone Number *

Full Name of the Deceased *

Today's Date *

Date of Funeral or Memorial Service *

Name of Funeral Home, City *

(Choose one) Would you like the eulogy to be written in *

First Person - "My Mom was a great woman . . ." Third Person -"Dora Stark was a great woman . . ."

Did he/she have a nickname *

How old was he/she? *

Date of Birth *

Date of Death *

Was he/she married? *

If married, for how long? *

Is spouse still living? *

What was/is spouse's name? *

When were they married? *

Do you know when and where and how they met? Please share that story here. *

His/her parent’s Names: *

Was ancestry something that influenced his/her life? If so, please explain. *

Did he/she have children? *

If so, how many children? *

Children's Names and Ages please: *

Any Stepchildren? *

Stepchildren's Names and Ages please: *

Grandchildren? *

Grandchildren Names and Ages please: *

Great Grandchildren? *

Great Grandchildren Names and Ages please: *

Any other important inter-generational relationships? *

Do children and grandchildren live in the area? *

Did they see him/her frequently? *

Describe their relationship: *

Names of siblings (Please designate whether they are living or deceased): *

Had he/she been ill for a while or did he/she die suddenly? *

If an illness, how long was it? *

Did he/she suffer much? *

Were his or her mental faculties sharp at the end or had dementia set in? *

Was he/she living independently or in a nursing/rehab facility? *

Did he/she ever talk about his/her childhood? *

What childhood stories did he/she tell? *

Additional space for childhood stories: *

Any stories about teen and young adult years? *

Additional space for teen/young adult years: *

What education level did he/she reach? *

Where? What was his/her major? *

Did he/she ever serve in the military? *

Which branch? *

Where? *

Any stories? *

Additional space for military stories: *

Did he/she have any obstacles to overcome in his/her life (like chronic illnesses or handicaps or crisis)? *

Additional space: *

Would you describe him/her as quiet or outgoing or something else? *

How would you describe his/her outlook on life (sunny, somber, pensive, reflective, happy-go-lucky...)? *

What did he/she do for a living? *

How many years? *

Retired? *

Did he/she enjoy the work? *

Any other employments? *

Are there any stories about his/her work life that you remember? *

Additional space: *

Name three things he/she enjoyed doing? *

What do you think he/she would say were the biggest achievements of his/her life? *

Additional space: *

What do you think he/she was most grateful for in life? *

Additional space: *

What was most important to him/her? *

Additional space: *

What would come in second most important? *

Additional space: *

Do you think he/she had any regrets about his/her life? *

Additional space: *

Was he/she a religious person? *

If so, to what extent? *

Where? *

Was he/she involved with any clubs or other organizations? *

Did he/she hold a leadership position? *

How many years? *

Who were his/her closest friends? *

How did they meet? *

What kinds of things did they do together? *

Additional space: *

What were his/her favorite pastimes or hobbies? *

What other talents or skills did he/she have? *

What would you say might have been the greatest day or days of his/her life (other than children being born)? *

Additional space: *

What three words do you think best describe him/her? *

Is there some phrase or words he/she always used - some expression uniquely his/hers? *

What did it mean? *

Did he/she grow up in city, state of death/funeral? *

If not, what brought him/her to this city and/or state? *

What trait or characteristic or value do you think he or she would most like to have passed on to the next generations? *

Additional space: *

Did he/she have any pets? *

Describe them please: *

Did he/she enjoy music? *

Any favorite songs? *

What kind? *

How do you think he/she influenced the lives of those he/she knew? *

Additional space: *

To what extent? *

If someone were to ask you what he/she was like, what would you say in one sentence? *

May we quote you? *

A second quote from someone else if others are working with you completing this questionnaire: *

Who is writing this sentence? *

What is your relationship? *

May we quote you? *

What special memory of him/her do you have - something you did together or something he/she said or some quirk he/she had. *

Additional space: *

Are there some things you think would be important to mention about him/her in describing his/her life that we haven't asked? *

Additional space: *

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