First name:

Last name:

Middle initial:

Date of birth:

Birthplace:

Social Security #:

Address:

City:

Inside Lakeland city limits: Yes  No

State:

Zip:

County:

Country:

Home phone:

Sex:

Race:

Occupation:

Year retired, if applicable:

Marital status:

Spouse's name:

Spouse's DOB:

Spouse's SSN:

Mother (with maiden name):

Father:

Former residence:

Church affiliation:

Highest level of education obtained:

Degree obtained:

Ever served in the armed forces: Yes  No

If veteran, conflict served:

Military branch:

Service number:

Years served:

Retired: Yes  No

Awards or medals:

Lodges/Clubs/Etc:

Additional information:

The following information can be discussed in detail with our Gentry-Morrison staff (863-688-7679).

Preference: Burial  Cremation

Name of cemetery:

Location (address with city):

Embalming (not required by law): Yes  No

Visitation: Yes  No

Location of visitation:

Memorial service: Yes  No

Location of service:

Vet/Lodge participation: Yes  No

Vet/Lodge contact:

Memorial donations:

Surviving relatives: