UUSGU | Memorial Planning Form

Unitarian Universalist Society of Grafton & Upton

Memorial Planning Form for Church Members

This confidential information is intended for the minister’s review only.*

Name__________________________________ Phone____________________ Email____________________

Address ______________________________________________________________________________

Persons to contact for legal purposes (next of kin, friend, attorney, etc).

Name__________________________________ Phone____________________ Email____________________

Address __________________________________________________________Relationship________

Name__________________________________ Phone____________________ Email____________________

Address _________________________________________________________Relationship_________

Name__________________________________ Phone____________________ Email____________________

Address__________________________________________________________Relationship________

If I am beset with a sudden or terminal illness:

My physician is: __________________________________ Phone__________________________________

Address______________________________________________________________________________

I have a Directive to Physicians? ___ Yes ___ No

I have a DNR (Do Not Resuscitate) order? ___ Yes ___ No

I have a durable Power of Attorney. ___ Yes ___ No

Healthcare decisions may be made on my behalf by: _____________________________________

I desire the service of Hospice. ___ Yes ___ No

My next of kin or significant persons are aware of my wishes? ___ Yes ___ No

Final Arrangements:

I have existing arrangements with a funeral home. ___ Yes ___ No

If yes, the Funeral Home is: _______________________________________________________________

I want a memorial service. ___ Yes ___ No

If yes, the service could be held: ___ Church ___ Funeral Home ___ Other (_______________)

I wish to be cremated. ___ Yes ___ No

I would like my ashes: _______________________________________________________________________

I wish to be buried. ___ Yes ___ No I own a cemetery plot. ___ Yes ___ No

Location of the plot: __________________________ Location of deed: ____________________________

I have prepaid all expenses connected with my burial or cremation. ___ Yes ___ No

If no, such expenses will be handled by: ____________________________________________________

I have told survivors where the following information is located?

Durable Power of Attorney ___ Yes ___ No

Long-term Care Instructions ___ Yes ___ No

Social Security & Medical Cards___ Yes ___ No

Latest Will & Testament ___ Yes ___ No

Insurance Policies ___ Yes ___ No

Passport ___ Yes ___ No

Copy of Credit Cards (front and back) ___ Yes ___ No

Mortgage Documents ___ Yes ___ No

Safe Deposit Box ___ Yes ___ No

About confidentiality:

As member of the Unitarian Universalist Society of Grafton and Upton, you may expect the information above to be kept completely confidential. It will be kept in a locked file and shared with no one without your written consent. Upon receiving news that you are beset with a sudden illness, trauma or death the minister will review the information and execute your wishes as honorably as possible within legal limits. As a member of UUSGU, you and your survivors are entitled to reasonable ministerial services, without fee, including the presentation of your service. The information below will be invaluable in preparing a meaningful and memorable service that celebrates your life. Your thoughtful response is greatly appreciated.

Please include these items in my Memorial Service:

My favorite Hymns from our hymn book:

Title__________________________________________________ Page # ______________

Musical selections I would like played on the piano or from a recording:

Source: ____________ Selection: _______________________________________________

My favorite Readings or Poems:

Source: ____________ Selection: _______________________________________________

People I would like to speak:

Name__________________________________ Phone____________________ Email____________________

Address__________________________________________________________Relationship________

Name__________________________________ Phone____________________ Email____________________

Address__________________________________________________________Relationship________

Name__________________________________ Phone____________________ Email____________________

Address__________________________________________________________Relationship________

I have prepared (or arranged for) these service items:

Memory Table ___ Yes ___ No Order of Service ___ Yes ___ No

Video ___ Yes ___ No Nametags ___ Yes ___ No

Obituary ___ Yes ___ No Guest Book ___ Yes ___ No

Questions to help personalize your service: (please use additional pages as needed)

What words would you use to describe yourself?

What are your particular loves or hobbies?

If you could name one value or lesson you most want to teach the next generation, what would it be?

What one achievement or accomplishment are you most proud of?

What are some of your favorite phrases or sayings?

Have you ever put anything up on the wall—a picture or motto that expresses who you are?

Do you have any nicknames?

Is there a cause or a movement that you have felt deeply about and supported with your time and resources?

If you could have one thing said about you during your service, what would it be?

In what ways do you think this world is a little different because of you?

Please attach a copy of the obituary you would submit to the newspaper.

Please attach, also, a resume of your personal, academic and business achievements as well as any anecdotal information about yourself that may be helpful to those speaking at your service.