EOL Planning Worksheet March2008
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PERSONAL PLANNING SHEET FOR (Name) General Information Street Address Date of Birth City, ST Zip Emergency Contact(s) Phone Veteran Branch and Dates of Service Have been made Need to be made Need Developed Can be made when needed according to this plan In effect Funeral Home Designated agent(s) Phone Location of Document Contact Desire Home / Hospice Care Preferences and Arrangements Obituary Notes: Services Select any and all options that denote your preferences None Religious Affiliation, if any Private Public Graveside Only Eucharist / Last Rites Rosary Visitation Viewing Funeral Celebration of Life Mass of Christian Burial LOCATION: Church Synagogue Other Location Preferred Officiant (Name & Title) Name of Location Street Address City, ST Zip Phone ( ) — Clothing to be dressed in: Other specific details: Music None Instrumental Vocalist Congregational Singing D C Living will / medical power-of-attorney Songs E (If checked, Contact Regional Veterans Affairs) A B Advance Directives Pre-arrangements Print Name Signature Date .. Page 1 of 3
description
End of Life Planning Worksheet to help start the process of defining your preferences for handling your services, disposition of your remains and associated issues. NOT A LEGAL DOCUMENT and DOES NOT replace a will, trust or other legally binding documents.
Transcript of EOL Planning Worksheet March2008
PERSONAL PLANNING SHEET FOR(Name)
General InformationStreet Address Date of Birth
City, ST Zip Emergency Contact(s)
Phone
Veteran Branch and Dates of Service
Have been made
Need to be made Need Developed
Can be made when needed according to this plan In effect
Funeral Home Designated agent(s)
Phone Location of Document
Contact Desire Home / Hospice Care
Preferences and Arrangements Obituary Notes:
Services Select any and all options that denote your preferences
None Religious Affiliation, if any
Private Public
Graveside Only Eucharist / Last Rites Rosary
Visitation Viewing
Funeral Celebration of Life Mass of Christian Burial
LOCATION: Church Synagogue Other Location
Preferred Officiant (Name & Title)
Name of Location
Street Address
City, ST Zip
Phone ( ) —
Clothing to be dressed in:
Other specific details:
Music
None Instrumental
Vocalist
Congregational Singing
D
C
Living will / medical power-of-attorney
Songs
E
(If checked, Contact Regional Veterans Affairs)
A
B
Advance DirectivesPre-arrangements
Print Name Signature Date ..Page 1 of 3
PERSONAL PLANNING SHEET FOR(Name)
Services (Cont'd)
Scripture Verses
Inspirational
poems, quotes
or thoughts
Flowers
None
Reception Wake Other
Name of LocationStreet Address
City, ST Zip Phone ( ) —
Final Disposition Preferences (See Section G for Disposition Location)
Burial
NO Burial Casket Preferences
Wood Fiberglass Other
Metal Plastic
Color / Liner Preferences:
Cremation
NO Cremation Container Preferences (wood, ceramic, color, etc.)
Urn
Box
Disposition Preferences Burial Vault Dispersed
Donation
NO Donation
Registered as an organ donor
MVD designation
Permission to register on donor list
Donation to Science / Education
Specific school
Specific program
Type(s) Color (s)E
(Note: See Section G for specifics of location or other handling.)
Specify all or some, note your preferences
F
Kidney Eyes Heart Lungs Liver
Pancreas Skin Grafts Intestinal Tissue
Print Name Signature Date ..Page 2 of 3
PERSONAL PLANNING SHEET FOR(Name)
Final Disposition Location
Desired Location (City, State)
Cemetery desired
Already purchased Need to purchase
Single Plot
Double Plot adjoining:
Single Vault
Double Vault adjoining
Headstone / Marker / Monument Single Double
Already purchased Need to purchase
Color / Stone type
Insignia / symbols / images
Inscription Preferences
Ashes Dispersed By Whom
Location(s)
Additional Instructions & Comments Regarding Arrangements & Preferences
Property & Affairs Note: This does not replace legal documents; legal documentation is strongly recommended.
Estate Trust Executor(s) or Estate Representative(s) designation
Legal document location(s)
Will
Other
Location of documents regarding disposition of personal property and effects
My Message to Loved Ones (How I hope to be remembered / My legacy / You must go on)
G
H
J
I
Print Name Signature Date ..Page 3 of 3
