"The option that relieves the burden from your family"

One of the most loving, caring things that an individual can do is leave behind details and information in regard to Pre-need. If you feel it is too hard to discuss funeral arrangements at this time, just think how difficult it would be for your loved ones at a time of loss.

Advantages Of Planning Your Funeral Arrangements
  • Pre-need will express your wishes.
  • Pre-need relieves your family from making difficult decisions at a time of emergency.
  • Pre-need will give you and your family the security and satisfaction knowing that all the arrangements have been planned and paid for.
  • Pre-need discounts for complete funeral packages save you money.

Siwicki-Yanicko Funeral Home is independently owned and operated 
and not affiliated with any cemetery or national chain.

Member of pfpa ( Professional Funeral Planners Assoc. )

If you are ready to begin the Pre-Need process, give us a call at 724-265-3800, or fill in the form below.
Personal Information
Name
(First MI Last):
Marital Status:   Social_Security #:
Date of Birth: Place Of Birth:
Address:
City: State:
County: Zip:
Phone: E-mail:
Spouse's Name: Spouse's Maiden Name:
Place of
Marriage: 		Date of Marriage:
Father's Name: Mother's Name:
Mother's Maiden Name:
Person in Charge:
Address:
Phone:


Work/Education History
Education (0-12):
 College 1-5+:
Occupation:
Business:
 Company:
Schools Attended and Graduation Years

Military Record
Branch of Service: Serial Number:
Date Enlisted: Rank At Discharge:
Date Discharged: Discharge On File At:
Copy of Discharge Papers:     Yes     No
Name Of Wars:

Funeral Service Request
Place Of Service:
   
Length of Visitation:
Religious Denomination:
Place Of Worship:

Newspaper Information (Please list family members)
Spouse:
Parents:
Children:
Brothers/Sisters:
Number of Grandchildren:
List any other significant relatives :

Special Instructions
Lodges, Organizations, and Offices held:
Jewelry:
Glasses:
Lodge / Union:
Person in Charge of Final Arrangements:
Clothing Preference: My own Other
Funeral Luncheon Site:


Disposition Request
I Prefer:
Cemetery:
Address: Phone:
Section:
I have made a last will and testament:     Yes     No
Location:

If Cremation, final disposition of cremated remains should be?
Burial Location:
Scattering Location:
Received By:


Other Instructions

Memorials/Donations To Charity

Please select all that apply:
Send information about pre-arrangement

Contact me to set an appointment

Please keep my information on file


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