Immediate Need

Immediate Need

Full Name:

Date of Death:

Address:

Telephone Number:

Email Address:

Date of Birth:

City and Province of Birth:

Father's Name:

Father's City of Residence:

Mother's Name:

Mother's City of Residence:

Mother's Maiden Name:

Spouse's Name:

Spouse's Maiden Name:

Survivors' Names and Cities of Residence:

Relatives Who Have Preceded In Death:

Occupation:

Business Type:

Company Name:

Church Membership:

Lodge or Union Name:

Veteran:

Branch of Service:

Serial Number:

Date Enlisted:

Date of Discharge:

Rank at Discharge:

Location of a Copy of Discharge (DD214):

Time of Military Service:

Military Honors at Graveside:

Flag Preference for Service:

Type of Service:

Visitation Hours:

Casket:

Person in Charge of Arrangements:

Officiating Clergy:

Pallbearers:

Flower Preference:

Music Selection:

Jewelry:

Glasses:

Casket Preference:

Disposition:

Outer Container Preference (for ground burial):

Cemetery Name:

Cemetery Location:

The Cemetery Property is in the Name of:

Miscellaneous Notes and Instructions:

Please select one of the options below:

Please send me information

Please contact me to schedule an appointment

Please place my information on file

Reiff Family Center - Funeral Home & Crematory

216 3rd Ave. SE. Independence IA 50644

FAX 319-214-7503

office@reifffamilycenter.com

319-935-3503

Reiff Family Center - Winthrop

224 220th Street West Winthrop IA 50682

FAX 319-214-7503

office@reifffamilycenter.com; ben@reifffamilycenter.com

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