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OUR LOCATION
ABOUT US

Online Preplanning Form

Planning in advance is about making your wishes known and we've created this simple online form to assist you. You may fill out as much or as little as you wish, but we do need your basic contact information so we can follow up with you to get any additional information we may need to complete your arrangements.

If you have any questions, or would like assistance with this form, please call (920) 748-2623 or our toll free line at 888-801-8111

Online Preplanning Form

Section 1

About You

First Name*

Middle Name

Last Name*

Maiden Name

Phone Number*

Email Address

Home Address*

Line 2

City*

State*

Zip Code*

Who are you filling this form out for?*

Myself

A Family Member

Family member's relationship to you?

Spacer 0

Section 2 - Skip this section if you are filling this form out for yourself

Personal Information of Family Member

First Name

Middle Name

Last Name

Maiden Name

Home Address

Line 2

City

State

ZIP Code

Spacer 1

Section 3

If you are filling this form out for yourself, fill in your information. If you are filling it out for a family member, please fill in their information.

Did this person serve in the military?*

Yes

No

If 'Yes', which branch?

Which race or ethnicity best describes this person?

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic

White / Caucasian

Multiple Ethnicity / Other

If Multiple or Other, Please Specify

Place of Birth:

Place of Birth

Date of Birth*

City of Birth*

State of Birth*

Family Information

Family Information

Father's Name

Mother's Name

Mother's Maiden Name

Marital Status*

Spouse's Name *Required if applicable

Spouse's Maiden Name *Required if applicable

Place of Marriage

Date of Marriage

Free Text

Education History

Highest Level of Education*

School Name

School Location

Free Text

Work History

Occupation*

Type of Industry*

Wishes

Wishes

Is burial or cremation preferred?

Burial

Cremation

Opt-In

Private viewing prior to cremation?

Visitation Options

Visitation at Funeral Home

Visitation Elsewhere

No Visitation

Funeral Service Option

Funeral service at funeral home

Funeral service elsewhere

No Funeral Service

Final Disposition

Ground Interment (burial)

Mausoleum Entombment (above ground burial)

Columbarium (for cremation urns)

Ashes returned to family

Free Text

Preferences

Please list any musical selections to include in the services.

Please list any interests or hobbies to include in the obituary.

Thank you for contacting us.
We will get back to you as soon as possible.

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Contact Us

515 Mayparty Dr | PO Box 371
Ripon, WI 54971

Phone | Text: (920) 748-2623
Toll Free: (888) 801-8111

Email : info@ButzinMarchant.com

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