Funeral & Cremation Planning - Miller-Dutra Coastside Chapel

Planning

HALF MOON BAY, CA | 645 Kelly Avenue, Half Moon Bay, CA 94019 | (650) 726-4474

Everyone benefits by planning ahead.

When you preplan your arrangements, you spare your family from the unnecessary stress associated with worrying about making the wrong decision.

To make this even easier for you, we can keep your wishes on file at Miller-Dutra Coastside Chapel at no charge.

Talk with one of our preplanning specialists today to learn more about the greatest gift you can give to your loved ones.

For your added convenience, we’ve created a simple form to help you get started.

Information About the Person Completing This Form
I am planning for*
Name*
First Last
Middle
Phone*
Email
Address
Street Address Address Line 2 City State ZIP Code
County
Show Detailed Form?
- Yes
- No
Information About the Person For Whom You Are Planning
Name
First Last
Middle
Gender
Marital Status
Date of Birth
Month
Day
Year
Place of Birth
Spouse's Full Name
Spouse's Maiden Name
Place of Marriage
Date of Marriage
Month
Day
Year
Mother's Name
Mother's Maiden Name
Father's Name
Work and Education
Education (Primary)
Years Attended
College (1-5+)
Years Attended
Usual Occupation (most of life)
Kind of Business
Company
Military Records
Branch of Service
Serial Number
Dishcharge on file at
Date of Dishcarge
Month
Day
Year
Rank at Discharge
Copy of Discharge
- Yes
- No
Names of War(s)/Conflict(s) Toured
Funeral or Memorial Service Preferences
Place of Service
Name of Funeral Home
Address
Phone
Place of Visitation
I prefer the funeral service to be
Viewing of Family
- Yes
- No
Viewing of Friends
- Yes
- No
Religious Denomination
Place of Worship
Lodge/Union
Person(s) to Finalize Arrangements at Time of Death
Full Name
Street Address
City
State
Zip
Phone
Special Instructions
Flower Preference
Music
1.
2.
3.
4.
5.
6.
Jewelry
Glasses
Clothing
Other
Disposition Options
I prefer
Cemetery
Address
Phone
Section
I have made a Last Will and Testament
Other Information and Special Instructions
Please list any other instructions you would like us to have
Memorials and Charities
Please list any memorials or donations that you would like
Contact Options
- Send information about pre-arrangement
- Contact me to set an appointment
- Please keep my information on file
Phone
This field is for validation purposes and should be left unchanged.

Planning

Everyone benefits by planning ahead.

Information About the Person Completing This Form

Information About the Person For Whom You Are Planning

Work and Education

Military Records

Funeral or Memorial Service Preferences

Person(s) to Finalize Arrangements at Time of Death

Special Instructions

Disposition Options

Other Information and Special Instructions

Memorials and Charities

Contact Options