INFORMATION AND INSTRUCTIONS ON FINAL AFFAIRS

Name ________________________ Date ________

Address ________________________ Soc. Sec. No. ________________

I request that the Religious Society of Friends carry out the following upon my death:

The information below may help those responsible carry out my wishes:

1. Persons to notify at once: (next of kin, co-workers, executor, &c.)

Name ________________________ Name ________________________

Address ________________________ Address ________________________

Telephone ________________ Telephone ________________

Relationship ________ Relationship ________

2. Member of memorial society:

Address ________________________ Telephone ________

3. Disposal of body: burial __   cremation __   medical research __   organ donations __

Disposal of ashes ________________

Cemetery preferred ________ Common plot ________

Location of deed ________________ Family plot ________

Location of release papers ________________________

Undertaker preferred ________________

4. Burial insurance: Insurance company ________________

policy number ________________

If no insurance, expenses to be met as follows: ________________________________

5. Memorial meeting for worship desired? ________

Special requests: ________________________

6. Flowers accepted ________ Where ________________

In lieu of flowers, contributions may be made to: ________________________

7. Special instructions if death is distant from home: (over)

8. My will is located at ________________________

________________________________________

9. If no surviving parents, instructions on care of minor children: (over)

10. Information for death certificate (must agree with legal records and policies):

Full legal name ________________________

Present address ________________________

Birth date ________ Birth place ________________ Citizenship ________________

Occupation ________________ Present employer ________________

Job title ________________ Address ________________________

Father's full name ________________________

Mother's full name ________________________

    11. My signature to this document ________________________

    Received for the monthly meeting: date ________________________________

    (clerk's or recorder's signature)

    ________________________ Monthly Meeting

    (print monthly meeting name)

    Address ________________________

    The New York Yearly Meeting of the Religious Society of Friends