Duesterberg-Fredrick Funeral Home
521 Vigo Street
Vincennes, IN 47591
(812) 882-8721
(812) 882-5804.
Wampler Shaw Chapel
118 North Washington Street
Bicknell, IN 47512
(812) 735-3388

Last Name:
First Name:
Middle Name:
Suffix:
Email Address:
Address:
City:
County:
State:
Zip Code:
Phone:
Personal Information
Vital Statistics
Marital Status:
Social Security Number:
Date of Birth:
Place of Birth:
Spouse's Name:
Spouse's Maiden Name:
Place of Marriage:
Date of Marriage:
Father's Name:
Mother's Name:
Mother's Maiden Name:
Occupation:
Business:
Company:
Education (0-12):
College (1-5+):
Branch of Service:
Serial Number:
Enlistment Date:
Rank at Discharge:
Date of Discharge:
Discharge on File at:
Copy of Discharge Papers:
Name of Wars:
Place of Service:
Funeral Home:
Place of Visitation:
Religious Denomination:
Place of Worship:
Lodge/Union:
Person in Charge of Final Arrangements:
Flower Preference:
Music:
Casket Bearers:
1.
2.
3.
4.
5.
6.
Jewelry:
Glasses:
Clothing:
Other:
I Prefer:
Cemetery:
Address:
Phone:
Section:
Location:
I have made a last will and testament:
Please list any other instructions you may have:
Work/Education
Military Service
Funeral Information
Disposition Request
Other Instructions
Copyright 2007 Duesterberg-Fredrick Funeral Homes
Any questions or comments please email jonmckee@wabashwebdesign.com
YesNo
YesNo
YesNo
YesNo