Infomation Form

Complete the form below to provide Leonard Johnson Funeral Home with need information concerning the death of your loved one:

Contact Person:

Name:

Address:

City: State: Zip Code:

Phone Number: 1---

Email Address:

Deceased's Information:

Name of Deceased:

Address:

City: State: Zip Code:

Date of Birth:

Age:

Duration of Final Illness:

Place of Death:

Date of Death:

Time of Death:

Occupation:

Church Affiliation:

How long resident here:

Veteran of:

Education:

Lodges and Clubs:

Other Information:

Preceded in death by:

Husband or wife (wife's maiden name):

Father and Mother (mother's maiden name):

Children:                                          Address:

Sisters:                                            Address:

Brothers:                                          Address:

Grandchildren:

Great-Grandchildren:

Great-Great-Grandchildren

Funeral or Memorial Service
Date:
Time:
Place of Service:
Visitation Time:
Clergy:   Phone:
Casket:
      Open
      Closed
Cemetery:
In Lieu of flower - donation made to:

Family Cars:
Where:
Pick up time:

Clothing:
Jewelry:

Flowers for top of casket
Family will order
Funeral home will order
Type of flowers to order:
How to dispose of the flowers after the service:

Memorial folders:
Hairdresser:
Make-up:
Glasses:

Picture in orbit for the newspaper
yes
No

When would family like first viewing:

Active Pallbearers
Names:	Phone Numbers:







Music
Organist:
Tapes:
CD's:

Number of death Certificates Needed:
Decedent's Name:
Address:
City:
State:
Zip Code:

Sex:
Date of Death:
Race:
Martial Status:
Inside City Limits:	YesNo
Social Security Number:	- -
Age:
Date of Birth:
Birthplace:
Armed Forces:
Surviving Spouse (if wife, maiden name):
Occupation:
Business Industry:
Years of Education:
Father's Name:
Mother's Name (maiden name):
Place of Death:
County:
Doctor's Name:
Phone:
Informant's Name:
Address:
City
State:
Zip Code:

1118 Virginia Street East
Charleston, WV 25301
Tel: 304.342.8135
Toll Free: 800.423.0648
E-mail: infol(at)barlowbonsall.com