Lyles Funeral Service

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Lyles Funeral Service
P.O. Box 397
Purcellville, VA 20134
Voice/Fax: 540-338-3709

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PERSONAL INFORMATION
BIOGRAPHICAL INFORMATION

Name: First: Middle: Last:

Street: City: State Zip

Marital Status: Married Single Widowed Divorced

Date of Birth: Birthplace:

Length of Residence Here:

Other Places and Lengths of residence:

Hispanic Origin: Yes No Specify:

Education: Elementary 1-12 College: 1 2 3 4 5+

Name of Spouse: First Middle: Maiden:

Father's Name: First: Middle: Maiden:

Mother's Name: First: Middle: Maiden:

Social Security Number:

If Veteran, Location of Discharge Papers:
Date Enlisted: Date Discharged:

Location of Will:

Occupation: Kind of Business:

Years Worked: Retired: Yes No If so, when:

Memberships: (Church, Clubs, Lodges, Etc.)

Immediate Survivors: To Include Spouse, Parents, Children, Brothers, Sisters, Grandparents, Grandchildren

Name: City/State Phone Relationship

Number of Grandchildren:
Number of Great-Grandchildren:

MEMORIAL SERVICE INFORMATION

Type of service desired: Public Private Graveside only

Memorial with: Body Present Body Not Present

Place of Memorial Service: Church Funeral Home Other

Public Visitation: Yes No

Casket Open: At Visitation Yes No Before Service: Yes No

During Service Yes No After Service: Yes No

Officiating/Minister:

Church:

Music Desired:

Suggested Pallbearers (6, More or Less, As Desired):

Memorial Contributions:

Other requests / Special Information:

Insurance Policies:

Company: Policy No.

DISPOSITION INFORMATION

Ground Burial: Yes No

Cemetery:

City: State:

Grave Description:
Lot: Block: Section: Grave:

Cremation: Yes No
Ashes Scattered: Burial:

Body Donation:

Location of Body Deed:

Additional Information, requests or questions:

DO NOT put copy in a safe deposit box as this information needs to be immediately accessible at time of death.

Signed: Date:
(If mailed in)

For more detailed information about preplanning or available funding options, you may contact Eric Lyles by phone at (800) 388-1913.

For more information regarding Forethought Life Insurance Company and their whole life insurance product that is offered through Lyles Funeral Service, click here.