Obituary Worksheet
___________________________, _____, __________________________________ passed away on ___________
Name of Deceased
Age
Residence: City & State
Date of Death
at _______________ o’clock at ________________________________. Funeral/memorial/graveside (circle one)
Time of Death
Place of Death (optional)
services will be held _______am/pm, ___________________, ___________________, 20_______ at
Time
Day of the week
Month & Day
Year
______________________________________, _______________________________________.
Place of Service
City, State
Visitation will be held ___________________________________________________________________.
Time, Date, Place
Mr./Mrs./Ms. ______________ was born ____________ in _____________________________________.
Last Name
Date of Birth
Place of Birth: City & State
Personal background (optional): __________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
He/she was preceded in death by (optional):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Survivors include:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Memorial contributions may be made to/In lieu of flowers: (please select)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Arrangements made by: _________________________________________________________________________
Name of Facility & Phone Number
Check all necessary boxes where obituary needs to be placed:
Photo
Newspaper _______________________
Newspaper __________________________
o
o
o
Newspaper _________________
Other __________________________
o
o
o
(Special Announcements)
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Obituary Worksheet