Bereavement Information
Please Print
Name of deceased ______________________________________________________________
(First name, middle, maiden, surname)
Date of birth ______________ Age _______ Occupation _________________
Date of death ______________ Cause of death ___________________________________
Address of deceased _____________________________________________________________
Parish of deceased _____________________________________________________________
Name of spouse _____________________________________________________________
Years married ______________ No. of children _____________________________
Contact person ______________________________
Relationship __________________
Phone nos. H, __________________ W, _________________ Cel, _________________
Address _____________________________________________________________
Email address _______________________________________________________________
Funeral Services
Name of Mortuary ______________________________Mortuary Coordinator ______________
Date of Wake (incl. day
of week) _________________________ Time ______________________
Place of Wake _______________________________ Body arrives at ____________________
Presider: _______________________________
Date of Funeral Mass (incl.
day of week) ____________________ Time ____________________
Place of Funeral _____________________________ Body arrives at ____________________
Presider: _____________________________
Date of Burial (incl. day
of week) _________________________ Time _______________________
Place of Burial ________________________________________
Presider: _______________________________________Burial or cremation____________
Mass (4) Music selections:
First Reading: ___________________________ Entrance Song: __________________________
Read by: ________________________________ Preparation Song: ________________________
Communion Song: _______________________
Second Reading: __________________________ Dismissal Song: __________________________
Read by: _________________________________
Responsorial reading: _____________________
Offer Gifts: Wine ________________________
Read by: ________________________________ Water _______________________
Eucharistic Minister: ____________________________
Assist: _____________________________
Music: _________________________________________ Assist: _____________________________
Kitchen: _______________________________________ Rosary: _____________________________
Intake completed by: _____________________________
Contact phone: _________________________
Comments:
Family provide table cloth for reception table.
Copy: (1) Father, (2) Family, (3) Secretary, (4) Original to Bereavement Folder
(updated 10-07)