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COVID-19 Funeral Assistance

We are very sorry for your loss and stand ready to assist you in your time of need. If you have not already scheduled a meeting with us, please call us.

If you prefer, you are welcome to send us information using the form below. We understand that you may not have access to all of the details below (or would prefer to provide in person). You are welcome to fill out as much or as little as you prefer. We will cover the remainder when we meet with you.

Funeral Service Form

Contact Name

Email Address

Relation to Deceased

Telephone

Does the Deceased Have a Pre-Arrangement on File with Us?

Full Name of Deceased

Date of Birth

Date of Death

Place of Birth

Time of Death

Type of Service

Service Location

Father's Name

Mother's Maiden Name

Mother's Name

Marital Status

Spouse's Name

Place of Marriage

Spouse's Maiden Name

Date of Marriage

Decedents Address

Decedents SSN (Please bring with you to our first meeting)

I agree to bring decedents SSN

Work/Education History

Occupation

Military Record

Did the deceased serve in the military?

YesNo

Branch of Service

Date Entered Service

Date Discharged

Serial Number

Rank at Discharge

Discharge on file at

Please list any hobbies, church or club memberships, or anything you would like to say in the obituary about your loved ones life.

Survivors: Please list any survivors that you would like included in the obituary. Include their relation, spouse, and city and state where they live.

Number of Grandchildren

Number of Great-Great Grandchildren

Number of Great-Grandchildren

Preceded in Death: Please list anyone that has preceded them in death that you would like to add in the obituary and their relation.

If you would like to have the ceremony outside of the funeral home please list the church, cemetery, or other location.

Minister and/or Speakers that will conduct the ceremony.

Special verses, poems, or sayings that you would like read at the ceremony.

Music: Please list song names and artist or person that will be singing (if singing live) that you would like at the ceremony.

Pallbearers: If you’re having a service with a burial please list the names of those that will serve as pallbearers.

Please list any other instructions or special requests about the service that you would like us to know.

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Cotrell Willow Ridge Funeral & Cremation Services
| 1100 Iron Bridge Rd
| Poplar Bluff, MO 63901
| Tel: 1-573-785-1200
|

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