You may fill out this form and print it using your browser print button and mail or fax it to:

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

Please use your "TAB" key to move from field to field.


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  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:


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

Music Desired:

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

Memorial Contributions:

Other requests / Special Information:

Insurance Policies:
Company: Policy No.


Ground Burial: Yes   No


City:   State:

Grave Description:
Lot:   Block:   Section:   Grave:

Cremation:  Yes   No
Ashes Scattered:

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.

Copyright 2001 Lyles Funeral Service. All rights reserved.