50 Bloomfield Avenue, Hartford, CT 06105 Tel: (860) 233-9897 / FAX 233-1333 Email: firstunitarian@ushartford.com Reverend Barbara Jamestone, PhD  HOME

The document below may be completed when you desire to indicate your wishes in the event of your death. The Form is confidential and should be returned to Reverend Sutherland. You may simply send this document to your printer. In the alternative, if you use Microsoft Word, you may download the Word file and print it. INSTRUCTIONS IN THE EVENT OF MY DEATH I. Personal Data: Full Name: ____________________________________ Date and place of birth: ____________________________ Address: ___________________________________________________ Phone: ___________________________ Occupation and Place of Work ________________________________________________________ Retired? Y or N Relationship Status: Married _____ Never Married _____ Widowed _____ Divorced _____ Partnered ______ Name of Spouse or Partner (even if divorced or deceased): _____________________________________ Living Relatives to be notified (please give name, address, phone and relationship): Father's Name _________________________ Place of Birth _______________________ Living or Deceased? ________ Mother's Name (maiden) ____________________ Place of Birth _____________________ Living or Deceased? _______ Military Service: Branch ___________ Unit or ship______________ Dates __________ Serial Number ______________ Organizations or club membership (sororities, fraternities, civic clubs, etc.) ______________________________________ Out of town newspapers to be notified _______________________________________________________ My personal papers (will, etc.) are located in __________________________________________________ I have a living will and its intentions are ______________________________________________________ Please attach a biographical sketch of yourself including major events and significant people in your life, career or occupation, major interests and hobbies, and general concerns. II. Disposition of Body A. Preferred funeral director (name and address) _______________________________________________ Preferred cost range for services (including casket, etc.) _______________________ B. Burial Cemetery (name, town, state) ______________________________________ Section _______ Lot ________ Deed to this lot is located at _________________________ Lot registered in name ___________________ Grave marker to read _____________________________________________________________________ C. Cremation Funeral Home or Cremation Society ____________________________________________________ Cremation prior to service ______________ After service _____________ (if viewing desired, see below) Ashes are to be scattered or kept at ___________________________________ (If cemetery, fill in items above) D. Medical Donation I wish to have certain parts of my body donated to science (designate parts) ____________________________ I wish to have my entire body donated to medical science at the following hospital or school: ________________ A copy of the instrument of donation is located at ________________________ IV. Funeral or Memorial Service A. Viewing of the Body or Visiting Hours Visiting Hours? Y or N _____________ Funeral Home _____________ Family home ___________ Other ________________ Casket Present? Y or N ____________ Open or Closed __________________________ Viewing immediately before service? Y or N _______________________________ B. Committal Service At graveside or crematory (designate) ____________________________ At place of scattering of ashes ___________________________________ C. Funeral or Memorial Service Funeral service desired (body present) Y or N__________ Casket open or closed during service ____________ Viewing immediately before service __________________________ Memorial service desired (no body present) Y or N _____________________ D. Suggestions for Service Held in Church _____________ Funeral Home ____________ Other _______________ Name and address of place __________________________________________________________ To be conducted by: Minister of above church ______________ Other personal friend _______________ General style or theology of service (e.g. traditional, theistic, Christian, humanistic, etc. ) Suggested speakers for testimonials _________________________________________________________ Suggested readings _______________________________________________________________________ Musical suggestions ______________________________________________________________________ Donations in lieu of flowers may be sent to _____________________________________________________ (charity, church or other group name and address) Suggested pallbearers ______________________________________________________________________ Date ____________________ Signature ___________________________________________________

Let us know of any comments, errors and corrections - thanks (revised 10/14/05) )