Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
PERSONAL INFORMATION
Full name
__________________________________________
Maiden name
__________________________________________
Street address
__________________________________________
City, state, zip code
__________________________________________
Previous address
__________________________________________
Are you an organ donor? ____ Yes _____ No
Do you have the proper documents completed? ____ Yes ____No
Who has those documents? ____________________________________
Have you arranged to donate your body? ____ Yes ____No
To what institution have you donated your donated body?
___________________________________________
Do you have a Living Will? ____ Yes ____ No
Who has the Living Will? _______________________________________
Do you have an Advanced Directives/Ohio Durable Power of Attorney for Health Care? ___ Yes ___ No
Who has this Durable Power of Attorney for Health care? ______________
What newspaper (s) should
receive the information for an
obituary?
____________________________________________
____________________________________________
Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
2
BIOGRAPHICAL INFORMATION
Place of birth
________________________________________________________
Date of birth
________________________________________________________
Social Security Number
________________________________________________________
Country of citizenship
________________________________________________________
Marital status
First spouse’s full name
Is your spouse still living?
___ single
___ married
___divorced
___widowed
________________________________________________________
____ yes
____ no
Date and place of marriage
________________________________________________________
Second spouse’s full name
________________________________________________________
Is your spouse still living?
Date and place of marriage
____ yes
____ no
_______________________________________________________
CHILDREN (Check box if the person is deceased.)
Child’s name

Child’s spouse
Address
___________________
____________________________
___________________
____________________________
___________________
____________________________
___________________
____________________________
___________________
____________________________
___________________
____________________________
___________________
____________________________
___________________
____________________________
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_____________________
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_____________________
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_____________________
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_____________________
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_____________________
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_____________________
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_____________________
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_____________________
Attach an additional sheet if needed.
GRANDCHILDREN (Check box if the person is deceased.)
Child’s name

Child’s spouse
Address

_____________________

___________________
____________________________
___________________
____________________________

_____________________
Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
Child’s name
3
Child’s spouse

Address

_____________________

___________________
____________________________
___________________
____________________________
___________________
____________________________
___________________
____________________________
___________________
____________________________
___________________
____________________________
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_____________________
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_____________________
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_____________________
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
_____________________


_____________________
Attach an additional sheet if needed.
GREAT-GRANDCHILDREN (Check box if the person is deceased.)
Child’s name
Child’s spouse

Address

_____________________

___________________
____________________________
___________________
____________________________
___________________
____________________________
___________________
____________________________
___________________
____________________________
___________________
____________________________
___________________
____________________________
___________________
____________________________
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_____________________
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_____________________
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_____________________
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_____________________
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_____________________
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_____________________
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
_____________________
Attach an additional sheet if needed.
Great-Great-Grandchildren
If you have great great grandchildren, please add those names on another sheet of paper.
PARENTS
Father’s name
Birthplace
Mother’s name
Birthplace
__________________________________________________________
_________________________
Is he living? _____ yes _____ no
__________________________________________________________
_________________________ Is she living?
Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
4
SIBLINGS: (Check box if the sibling is deceased.)
Sibling’s Name

Sibling’s spouse
Address
______________
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
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_______________
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_______________
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_______________
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_______________
Attach an additional sheet if needed.
EDUCATION:
Elementary school
______________________________
High school
______________________________
College
______________________________
Degree
____________________________
College
______________________________
____________________________
College
______________________________
____________________________
College
______________________________
____________________________
College
______________________________
____________________________
MILITARY
Branch
_____________________________________________________
Rank
_____________________________________________________
Serial Number
_____________________________________________________
Date and place of induction
_____________________________________________________
Date and place of discharge
_____________________________________________________
Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
5
CAREER
Occupation
____________________________________________________
Where did you work
Other place of long term
employment
Other place of long term
employment
____________________________________________________
____________________________________________________
____________________________________________________
COMMUNITY INVOLVEMENT
What church did you attend?
____________________________________________________
On what committees did you serve?
____________________________________________________
____________________________________________________
____________________________________________________
To what clubs and organizations do
you belong?
____________________________________________________
List any offices that you held.
____________________________________________________
____________________________________________________
Did you do volunteer work for any
community organization?
____________________________________________________
____________________________________________________
IMPORTANT DOCUMENTS
Please list where each of the following documents can be found.
Birth certificate
___________________________________________________
Marriage license
___________________________________________________
Military discharge papers
___________________________________________________
Children’s birth certificates
___________________________________________________
Last Will and Testament
___________________________________________________
Who is your attorney?
___________________________________________________
Funeral and cemetery documents
___________________________________________________
Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
6
Life insurance policy
___________________________________________________
Who is your agent?
___________________________________________________
Health/accident insurance
___________________________________________________
Who is your agent?
___________________________________________________
Property insurance policy
___________________________________________________
Who is your agent?
___________________________________________________
Deed for your home
___________________________________________________
Deed for other properties
___________________________________________________
Mortgages
___________________________________________________
Checking account bank
___________________________________________________
Checking account number
___________________________________________________
Additional checking accounts
___________________________________________________
Saving account bank
___________________________________________________
Saving account number
___________________________________________________
Stocks/Bonds/CD’s
___________________________________________________
Who is your investment advisor?
Credit card company and account
numbers
Living Will
___________________________________________________
___________________________________________________
___________________________________________________
Durable Power of Attorney for Medical
Treatment
___________________________________________________
Pension/retirement plans
___________________________________________________
Income tax records
___________________________________________________
Who is your accountant?
___________________________________________________
Automobile registrations
___________________________________________________
Other documents
Safety deposit box—bank, number, and
key
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
7
PLACE OF MY DEATH
If there can be a choice, I would like to die




at home
in the hospital
in a hospice
other: (specify) ______________________________________________________________
FIRST CONTACTS
The following people need to be informed immediately of my death.



______________________________
Name
______________________________
Name
______________________________
Name
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
MY PRIEST AND CHURCH
Please contact my priest and church immediately

______________________________
Name
______________________________
Address
______________________________
City, state
______________________________
Church
______________________________
Church Telephone
______________________________
Home telephone
Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
8
CONTACTING FAMILY AND FRIENDS
I would like for the following people to be informed of my death.









______________________________
Name
______________________________
Name
______________________________
Name
______________________________
Name
______________________________
Name
______________________________
Name
______________________________
Name
______________________________
Name
______________________________
Name
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
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______________________________
Name
______________________________
Name
______________________________
Name
______________________________
Name
______________________________
Name
______________________________
Name
______________________________
Name
______________________________
Name
______________________________
Name
______________________________
Name
9
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
______________________________
Address
______________________________
City, state
______________________________
Telephone
______________________________
Relationship
Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
10
FINAL DISPOSITON OF MY BODY
I want



to have my body donated to medical research
to donate any usable body parts
to have no part of my body donated





to be buried in a casket
entombed in a mausoleum
cremated with my ashes kept by _______________________________________________
cremated with my ashes buried in an urn at _______________________________________
cremated with my ashes not placed in an urn; instead the ashes are to be
__________________________________________________________________________
my casket or urn to be buried/entombed at ___________________________ Cemetery in
__________________________________________________________________________

DONATION OF WHOLE BODY TO MEDICAL RESEARCH
I have filed forms with ___________________________________ School of Medicine.
Contact: _____________________________________________________________


My body is to be donated immediately upon my death.
My body is to be donated after the funeral.
DONATION OF BODY PART
Separate forms for donation of body parts has been provided at the end of this document.
AUTOPSY
I want



Note:
no autopsy unless it is required by law or unless information can aid medical science
no autopsy unless it is helpful to my family
the final decision concerning an autopsy to be made by _______________.
Having an autopsy performed may make the body unusable by a medical school and may void
any contract that you have with that school.
EMBALMING
I want



the mortician to fully embalm my body.
the mortician to embalm my body only arterially until the body is delivered to the school of
medicine.
no embalming. I realize that burial or cremation must occur within 48 hours.
Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
11
CASKET / VAULT / URN
I want my casket to be constructed of




metal
wood
cloth-covered wood
cardboard



top of the line quality
middle of the line quality
the least expensive construction

I have already made arrangements for a casket with ________________________________
I want the vault to be constructed of



top of the line quality
middle of the line quality
the least expensive construction

I have already made arrangements for a vault with _________________________________
HEADSTONE



I have attached a sketch of the headstone that I want for my grave.
I have made arrangements with the funeral director for my headstone.
I have made arrangements with a monument company for my headstone. That company is
__________________________________________________________________________
VISITATION
I want to be dressed in the following:
Clothing
Glasses
________________________________
___________________________________
________________________________
___________________________________
________________________________
 yes
 no
___________________________________
Jewelry
________________________________
________________________________
________________________________
________________________________




remove before closing casket
do not remove
remove before closing casket
do not remove




remove before closing casket
do not remove
remove before closing casket
do not remove
Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
Other items
________________________________
________________________________
________________________________
________________________________
12

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





remove before closing casket
do not remove
remove before closing casket
do not remove
remove before closing casket
do not remove
remove before closing casket
do not remove
I would like the following to be placed in the coffin with me for the visitation:
________________________________
________________________________




remove before closing casket
do not remove
remove before closing casket
do not remove
I want friends and family members to come for the visitation at




my home
my church
the funeral home
another place __________________________________________________
I want the following religious service to occur before the visitation begins




none
prayers led by the family
prayers led by a priest
other ________________________________________________________



closed
opened for family and invited friends before the public visitation
opened
I want my casket to be
I would like the following floral arrangements
_____________________________________________________________________________
_____________________________________________________________________________
I would like for the following mementos to be displayed at the visitation
____________________________________________________________________________
____________________________________________________________________________
Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
13
MEMORIALS:


I want no mention of memorials in my obituary
In lieu of flowers memorial could be made to
______________________________
______________________________
______________________________
______________________________
THE FUNERAL
I want





a funeral service with the body present
a funeral service with the ashes present
a funeral/memorial service without the body/ashes
graveside services only
no service
I want the funeral service to be held
 at my church _______________________________________________________________

at the funeral home __________________________________________________________

at another location __________________________________________________________
Special services will be held by (fraternal, military, or spiritual group) _____________________________
at ___________________________________________________________________________
I would like for the following people to take part in my funeral service.
Name
Address
City
Telephone
Priests
1. ________________
 2. ________________
___________________
___________________
______________
______________
_____________
_____________
Deacons
 1. ________________
 2. ________________
___________________
___________________
______________
______________
_____________
_____________
Chalicer
1. _____________
 2. ________________
___________________
___________________
______________
______________
_____________
_____________
Reader
1. ________________
 2. ________________
 3. ________________
 Organist __________
___________________
___________________
___________________
___________________
______________
______________
______________
______________
_____________
_____________
_____________



Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
Name
14
Address
City
Telephone
___________________
___________________
___________________
___________________
______________
______________
______________
______________
_____________
_____________
_____________
_____________
___________________
___________________
______________
______________
_____________
_____________
Pallbearers
1. ________________
2. ________________
3. ________________
4. ________________
5. ________________
6. ________________
___________________
___________________
___________________
___________________
___________________
___________________
______________
______________
______________
______________
______________
______________
_____________
_____________
_____________
_____________
_____________
_____________
Honorary Pallbearers
1. ________________
2. ________________
3. ________________
4. ________________
5. ________________
6. ________________
___________________
___________________
___________________
___________________
___________________
___________________
______________
______________
______________
______________
______________
______________
_____________
_____________
_____________
_____________
_____________
_____________
Musicians
1. ________________
 2. ________________
 3. ________________
___________________
___________________
___________________
______________
______________
______________
_____________
_____________
_____________
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Acolytes
1. ________________
2. ________________
3. ________________
4. ________________
Ushers
1. ________________
2. ________________
Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
15
THE FUNERAL LITURY (The Burial Office)
Note: The Book of Common Prayer has prescribed services; if you would like to do some
things differently, talk with your priest. In some cases, changes can be made .
For the order of service, I would like to have the priest use _____ Rite I ____Rite II.
I ___ want ___ do not want communion to be celebrated during the service.
BIBLE READINGS
I would like the following lessons to be read:
_____________________________________
Book, chapter, verses
_____________________________________
Book, chapter, verses
_____________________________________
Book, chapter, verses
_____________________________________
Book, chapter, verses
_____________________________________
Book, chapter, verses
______________________________________
Book, chapter, verses
The following is a list of readings that are commonly read at funerals; if there are other readings that you
would like, discuss your choices with your priest.
From the Old Testament
1.
2.
3.
4.
5.
6.
7.
Job 19:21-27a
Ecclesiastes 3:111
Ecclesiastes 12:1-7
Isaiah 25:6-9
Isaiah 61:1-3
Lamentations 3:22-26, 31-33
Wisdom 3:1-5 (6-8) 9
(I know that my Redeemer lives)
(For everything there is a season)
(Remember your Creator in the days of your youth)
(He will swallow up death for ever)
(To comfort those who mourn)
(The Lord is good to those who wait for him)
(The souls of the righteous are in the hands of God)
From the New Testament
1.
2.
3.
4.
5.
6.
7.
Romans 8:14-19, 34-35, 37-39
(The glory that shall be revealed)
1 Corinthians 14:20-26, 35-38, 42-44, 53-58, or 15:50-58 (The imperishable body)
2 Corinthians 4:16-5:9
(Things that are unseen are eternal)
1 Thessalonians 4:13-18
(Therefore comfort one another with these words)
1 John 3:1-2
(We shall be like him)
Revelation 7:9-17
(God will wipe away every tear)
Revelation 21:2-7
(Behold, I make all things new)
From the Psalms
1.
2.
3.
4.
5.
6.
Psalm 23
Psalm 27
Psalm 42:1-7
Psalm 46
Psalm 90:1-12
Psalm 103: 13-22
Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
7.
8.
9.
10.
11.
16
Psalm 106:1-5
Psalm 116: (1-9) 10-17
Psalm 121
Psalm 130
Psalm 139:1-11
From the Gospels
1.
2.
3.
4.
5.
John 5: 24-27
John 6:37-40
John 10:11-16
John 11:21-27
John 14:1-6
(He who believes has everlasting life)
(All that the Father gives me will come to me)
(I am the good shepherd)
(I am the resurrection and the life)
(In my Father’s house are many rooms)
I would like to have the following non-Biblical readings also used in the service:
(Please attach a photocopy of each reading.)
_____________________________________
______________________________________
_____________________________________
______________________________________
MUSIC
I would like to have the following music played as a prelude:
_____________________________________ _______________________________________
_____________________________________ _______________________________________
I would like for the following hymns to be used during the service:
_____________________________________
______________________________________
__________________________________ ______________________________________
_______________________________ _______________________________
_______________________________ _______________________________
HYMNS
This is a list of hymns that are commonly sung at funerals; if there are other hymns that you would like,
discuss your choices with your priest.
Many people are unable to look at a list of hymns and know if it is the one that they really have in mind.
There are sites on the Worldwide Web that include a wide list of hymns; by clicking on the hymn, you can
then hear the music. If you are unsure, check with your priest; he can guide you.
Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
From The Hymnal 1982
687
662
405
208
460-461
671
488
656
516
652
608
383-384
287
594-595
677
362
517
335
490
425
482
657
8
691
396-397
42
411
680
655
659-660
410
390
685
345
645-646
209
439
618
A mighty fortress is my God
Abide with me
All things bright and beautiful
Alleluia, alleluia, alleluia, the strife is o’er
Alleluia, sing to Jesus
Amazing Grace
Be thou my vision
Blest are the pure in heart
Come down, oh love divine
Dear lord and father of mankind
Eternal father, strong to save
Fairest lord Jesus
For all the saints who from their labors rest
God of grace and God of glory
God moves in a mysterious way
Holy, holy, holy
How lovely is thy dwelling place
I am the bread of life
I want to walk as a child of the light
Immortal, invisible, God only wise
Lord of all hopefulness, lord of all joy
Love divine, all love excelling
Morning has broken
My faith looks up to thee
Now thank we all our God
Now the day is over
O bless the lord
O God, our help in ages past
O Jesus, I have promised
O master, let me walk with thee
Praise my soul, the king of heaven
Praise to the lord, the Almighty
Rock of ages
Savior, again to thy dear name
The king of love my shepherd is
We walk by faith
What wondrous live is this
Ye watchers and ye holy ones
From Lift Every Voice and Sing
234
69
192
72
54
60
38
106
101
14
115
God be with you till we meet again
I come to the garden alone
I need thee every hour
Just a closer walk with thee
Nearer my God to thee
O lord my God, when I in awesome wonder
On a hill far away…(The old rugged cross)
Precious lord, take my hand
Softly and tenderly
Soon and very soon, we are going to see the king
Spirit of God, the living God fall fresh on me
17
Planning Sheet for a Parishioner’s Death
and the Reading of the Burial Office
104
120
109
188
18
The lord is my shepherd
There’s a sweet. sweet spirit in this place
What a friend we have in Jesus
When peace like a river attendeth my way
From Wonder, Love and Praise
810
810
Eagle’s Wings
You who dwell in the shelter of the lord
I would like for the following music to be used as a postlude:
______________________________________ _____________________________________
______________________________________ _____________________________________
I would like for the following special arrangements to be made for the service:
_____________________________________________________________________________
_____________________________________________________________________________
AUTHORIZATION TO MAKE CHANGES
I authorize _________________________________ to make final decisions about my funeral with the
minister who is to officiate. This person is also authorized to make any necessary changes in other
details depending on his/her best judgement and the circumstances surrounding my death.
Signature
____________________________________________________________________
(the person planning his / her own funeral)
Date
____________________________________________________________________
Witnesses
____________________________________________________________________
____________________________________________________________________
Copies of these instructions have been given to:
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Some of the information in this document was taken from “The Rites of Burial” used at Trinity Episcopal
Church, Troy, Ohio and from “Some Thoughts on Preparing for Death and Burial” used at St. Mark’s
Episcopal Church, Dayton, Ohio. Louis Benavides prepared St. Mark’s booklet.