Is the person filling out the form also the funeral contact? *
Select… Yes No
Please contact via: *
Indicate preferred method of contact.
Select… Phone Text Email
Is the funeral contact also the next of kin? *
Select… Yes No
Deceased's Full Name *
Enter the name the way you would like it to appear on the front of the program. This could include maiden names and nicknames.
Was the deceased a member of Salem? *
Select… Yes No Unknown
Was the deceased baptized? *
Select… Yes, at Salem. Yes, at another church. Unknown No
Was the deceased confirmed? *
Select… Yes No Unknown
What type of service would you like? *
Select… Funeral or memorial service at Salem Graveside only No service Other
Has a funeral date already been confirmed with Salem staff? *
If yes, list the date in the "preferred date" field below. If no, list up to two preferred funeral dates in order of preference. We will check on school and church calendars and confirm the best date with you.
Select… Yes No
Visitation Information *
If there is no visitation, simply write, "None." If the visitation is being held at a funeral home, please indicate the location along with the time. If the visitation is at Salem, it will be during the hour prior to the service.
Funeral Home *
If you are not using a funeral home, simply write, "None."
Place of Burial *
If you have not selected a place of burial, write "Unknown."
Service Details
Please share with us a detailed description of the service, including musicians, songs, speakers, and special elements.
Will any friends and/or family members speak during the service? *
Select… Yes No
Notifying the Congregation
Our practice is to notify the congregation via email when a funeral is taking place. If you would prefer the congregation not to be notified, please indicate that below.
Select… Please do not notify the congregation.
Contact Name for Pictures and Program *
For clarity, please fill out this information even if it has already been entered on this form.
Contact Email for Pictures and Program *
For clarity, please fill out this information even if this email has already been entered on the form.
Phone Number *
Phone type Mobile Home Work Other
Please contact via: *
Indicate preferred method of contact.
Select… Phone Text Email
Would you like to request any specific Scripture passages? *
These Scripture verses can go on the front of the program, on the inside of the program, or be a read during the service. We are also happy to suggest passages if you don't have a preference.
Select… Yes No
Other Information
Any additional pertinent information: special requests, needs, favorite color, family connection to Salem, etc.
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