Health Care Directives and Medical Orders ❑ I have a living will. ❑ I have a durable power of attorney for health care. Health care agent’s name: Phon...
Health Care Directives and Medical Orders ❑ I have a living will. ❑ I have a durable power of attorney for health care. Health care agent’s name: Phone:
E-mail:
Address: Location of my advance health care directive: ❑ ❑ ❑ ❑ ❑
I have talked with my health care agent about my medical preferences. I have talked with my health care agent about palliative and hospice care. I have talked with my doctor and health care agent about do not resuscitate orders. I have an out of hospital do not resuscitate order. My doctor has entered medical orders for life-sustaining treatments.
Final Wishes Summary I wish to: be embalmed be cremated (see the Cremation Checklist) be an organ donor (see the Organ and Tissue Donation Checklist) have my body bequeathed to a medical school (see the Whole Body Donation Checklist) ❑ have my body buried in the earth (see the Burial Checklist) ❑ have my body entombed in a mausoleum (see the Entombment Checklist) ❑ other: ❑ ❑ ❑ ❑
I wish to have: ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
funeral service (body present) (see the Funeral/Memorial Service Checklist) memorial service (body not present) celebration of life service no service graveside service I would like a US flag covering my coffin I would like to have military funeral honors (see Veterans’ Burial Benefits Checklist) other:
My preferences are as follows:
Organ and Tissue Donation ❑ I wish to donate any needed organs or tissues. My blood type is ❑ I wish to donate only the following organs or tissues: Organs: ❑ ❑ ❑ ❑ ❑ ❑
❑ I have not prepared a uniform donor card. ❑ I have a uniform donor card. ❑ I have registered with my state’s organ donation registry at this website: Location of uniform donor card:
Whole Body Donation I have made the following prearrangements with the following medical school or research organization: Medical school: Address: Contact person:
Phone:
Research organization: Address: Contact person:
Phone:
Cremation ❑ I want my body to be cremated. ❑ I want my body to be cremated followed by a memorial service. ❑ I want my body to be cremated followed by a celebration of life service. I have made the following prearrangements for my cremation: Company: Address: Phone:
Website:
The contract is located Following my cremation, I wish my ashes be distributed as follows: ❑ ❑ ❑ ❑
Scattered in the following places: Placed in an urn and buried or entombed: Other: Handled as my loved ones see fit.
Burial The ownership of the cemetery lot is in the name of Location of the lot: Cemetery: Section:
Lot:
Address: Other description: Location of deed: ❑ I would like to have a grave marker. ❑ I would like to have a grave marker furnished by the Department of Veterans Affairs. ❑ I would like to have a service medallion furnished by the Department of Veterans Affairs. I would like the following words to be placed on my grave marker:
I would like the following type of casket: Other burial instructions:
Entombment The ownership of the crypt is in the name of Location of the crypt: Church/Cemetery/Mausoleum: Address: Space #: Other description: Location of deed or contract: I would like the following words to be placed on the crypt:
Other instructions:
.
Funeral/Memorial Service ❑ ❑ ❑ ❑ ❑
I want a funeral. I want a memorial service. I want a graveside service. I have not made funeral prearrangements. I have a pre-need contract and have pre-paid for some or all of my funeral.
I have made the following funeral pre-need arrangements:
The pre-need contract is located
.
I wish the commemorative service to be for: ❑ Friends and relatives ❑ Private ❑ Other: I wish the graveside service to be for: ❑ Friends and relatives ❑ Private ❑ Other: I want the casket to be: ❑ Closed ❑ Open The urn with ashes should be present: ❑ Yes ❑ No Location of the service: Funeral establishment: Address: Phone:
E-mail:
House of worship: Address: Phone:
E-mail:
Religious leader/Officiant/Clergy: Address: Phone: Speakers/Readers:
Ushers/Pallbearers:
Favorite scripture, psalms, poems:
Special hymns, music, musicians, soloists:
E-mail:
Veterans’ Burial Benefits ❑ ❑ ❑ ❑ ❑ ❑ ❑
I served in the US military. I or other family members may be eligible for veterans’ benefits. I have a copy of my DD-214. I want a burial flag for my casket. I want burial in a national cemetery. I want a veteran’s headstone. I want military honors at the burial.
Name I served under while in the military: First
Middle
Location of my DD-214: Date entered active service: Date separated from active service: Branch: Grade or rank: National Guard: Reserves:
Last
Will I have a will. Executor’s name: Phone:
E-mail:
Address: Drafting attorney’s name: Phone:
E-mail:
Address: Witness’s name: Phone:
E-mail:
Address: Witness’s name: Phone:
E-mail:
Address: The original of my will is located
.
Codicils I have executed a codicil to my will. Codicil date: Attorney’s name: Phone:
E-mail:
Address: Executor (if changed): Phone:
E-mail:
Address: Witness’s name: Phone:
E-mail:
Address: Witness’s name: Phone: Address: My codicil is located with my will:
E-mail:
Living Trust I have a living trust. Trustee’s name: Phone:
E-mail:
Address: Drafting attorney’s name: Phone:
E-mail:
Address: Witness’s name: Phone:
E-mail:
Address: Witness’s name: Phone:
E-mail:
Address: The original of my living trust is located
.
Pet Care I have made the following arrangements for the care of my pets:
I have made the following financial arrangements for the care of my pets:
Letter of Instruction I have a letter of instruction. Location of my letter of instruction: Date I last updated my letter of instruction:
Financial Power of Attorney ❑ I have a durable power of attorney for financial management. ❑ I have discussed my expectations with my agent. ❑ My agent has a copy of my durable power of attorney. Agent’s name: Phone: Address:
