Thomas P. Walsh Funeral Home, Inc.

60 Carleton Avenue

Central Islip, New York 11722

631-234-6314

 

 

Funeral Arrangements for

(This information will be needed for the

Death Certificate and to plan the Funeral Service)

 

 
Name:
Address:
Date of Birth:    Age:
Place of Birth:
Social Security Number:
Marital Status:
Spouse

                                                            (Maiden Name)
Veteran:

  Dates of Service:

Copy of Discharge or DD-214 needed for burial in Military Cemetery
Race:

  Hispanic Orgin:

                                                                                                           Specify Country
Education Level:
Usual Occupation:
Employer:
Address:
Father's Name:
Mother's Name:
Next of Kin:
Address:
Phone Number:
Doctor:
Address:
Phone Number:
Religion:
Church:
Cemetery:
Info: Plot#: Section: Range:
Casket to be:
Number of Days viewing:
Prefer:
Prefer:
Clergy Requested:
Prefer (in lieu of Flowers) Donations to:
Other Requests:
   

Surviving Relatives
Spouse:
Children:
Grandchildren:
Great Grandchildren:
Parents:
Brothers/Sisters:
 

 

  

Please print this form to take with you!!!

 

 

 

Independently owned and operated

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