1. What is your current age?
35-44
 
45-54
 
55-64
 
65-74
 
75 or over
     
2. Are you currently:
Employed
 
Retired
     
3. Have you ever been responsible for making funeral arrangements?
     
 
Never
 
Past 12 months
 
Past 12-24 months
 
Over 24 months ago
     
4. If you have given any thought to the subject, which of the following would you choose for yourself?
     
 
Burial
 
Cremation
     
5. How important to you personally is the location of the:
     
 
Funeral Home?
 
Cemetery?
     
6. How much might you expect to pay for a funeral?
     
 
Under $2,000
 
$4,000-$6,000
 
$8,000-$10,000
 
$2,000-$4,000
 
$6,000-$8,000
 
Over $10,000
     
7. Do you maintain up-to-date biographical information and accurate family records to assist you or a loved one with funeral planning?
     
 
Yes
 
No
     
8. Have you made final plans and arrangements for:
     
Cemetery property?
Yes
 
No
     
The type of funeral service you desire?
Yes
 
No
     
9. Are you aware that a prearranged funeral plan may help you qualify for Medicaid?
     
 
Yes
 
No
     
10. Are your loved ones and family members aware of what you would prefer for your own arrangements?
     
 
Yes
 
No
     
11. In the event of your death, who would make funeral arrangements?
     
 
Spouse
 
Child(ren)
 
Family Member
 
Other
     
12. Would it give you peace of mind to know you could do the planning in advance and that your family would not have to make arrangements?
     
 
Yes
 
No
     
13. Would you like free information about funeral planning and the types of services, which are available?
     
 
Yes
 
No
     
Name:
Street
Address:
City:
State:
 
Phone Number:
Best time to call :
Zip:
 
At Dee Funeral Home and Cremation Service, we have pre-planned options to fit almost any need and financial situation. Please contact us to receive a free guide to pre-planning.