Next-Of-Kin Form - Webster Groves Presbyterian Church Page 2
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2MY WISHES AT THE END OF MY LIFE
Name ________________________________________________
Date of birth __________________________
Place of birth _______________________
Spouse’s name ________________________ Alive ____ Deceased ____ Anniversary __________________
Name
Relationship
Phone
Family members:
_____________________________
__________________
________________________________
_____________________________
__________________
________________________________
_____________________________
__________________
________________________________
_____________________________
__________________
________________________________
Legal Information
Do you have an attorney? ______
Name and phone number: ______________________________
Do you have a Do Not Resuscitate (DNR) order? ______
Where is there a copy? __________________
Do you have a Will? ______
Where is there a copy? ______________________________________
Do you have a Living Will? ______
Where is there a copy? ______________________________________
general
Do you have a
Power of Attorney? _______
Name and phone number ____________________________________________________________________
health care
Do you have a
Power of Attorney? _______
Name and phone number ____________________________________________________________________
End-of-Life Plans
Name of funeral home _______________________________________________________________________
Name of cemetery/crematorium ______________________________________________________________
If applicable, body donation to _______________________________________________________________
Memorial Garden of Webster Groves Presbyterian Church: Niche _____
Burial _____
Paver _____
Type of service:
Funeral ______
Memorial service _____
Graveside only ______
With interment? ______
With interment? ______
With interment? ______
Meaningful scripture verses:
__________________________________________
____________________________________
__________________________________________
____________________________________
Special hymns/anthems:
_________________________________________
____________________________________
_________________________________________
____________________________________
Memorials: _________________________________________________________________________________
Signature ________________________________________________
Date _________________________
K:\Blythe\Congregational Care\NOK Form\Next of Kin Form.docx
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