Barry J. Farrell Funeral Home
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Information required for pre-arranged funeral
Please print, fill out, and mail completed form to:
Barry J. Farrell Funeral Home
2049 Northampton Street
Holyoke, MA 01040-3404
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Full name: ___________________________________________________________________________________
Street Address: ______________________________________________________________________________
City: __________________________ State: ___________________ Zip: ________________________
Telephone: _______________________ Sex: ________ Social Security Number: _____________________
Education: _________________________________ U.S. War Veteran: __________________________
Date of Birth: ______________________________ Birthplace: ________________________________
Married ______ Never Married ______ Widowed ______ Divorced ______
Last Spouse: _________________________________________________________________________________
Usual Occupation: ___________________________________________ Industry: ________________________
Fathers full name: ____________________________________________ State of Birth: ____________________
Mothers full name (Maiden) ____________________________________ State of Birth: ____________________
Religion: __________________________________________________
Services requested at: ___________________________________________________________________________
Clergy requested: ______________________________________________________________________________
I request: Burial _________ Cremation: ____________ Other _____________________________
Location of Burial: ___________________________________________________________________________
Casket Selected: ______________________________________________________________________________
Burial Vault: ______________________________________________________________________________
Executor/Executrix: ___________________________________________________________________________
Clubs/Organizations: _________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________.
Military Information:
Date entered into military: ________________________________________
Date of discharge: ________________________________________
Rank: _______________________________________
Service Number: _______________________________________
Branch of service: ________________________________________
Please list survivors as they should appear in obituary:
1. ___________________________________________ 6. ______________________________________
2. ___________________________________________ 7. ______________________________________
3. ___________________________________________ 8. ______________________________________
4. ___________________________________________ 9. ______________________________________
5. ___________________________________________ 10. ______________________________________
Family owned and operated since 1984
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