Forms for Planning
St. Mary Magdalene Episcopal Church
Life Planning and End-Of-Life Planning Forms
St. Mary Magdalene Episcopal Church has developed a series of forms to help you and those you love plan for emergency situations and end-of-life care.
It has nine separate easy-to-use sections that allow you to keep all your critical information in one document.
Each form is designed to be printed separately to allow you to share only those sections you want to share with various individuals.
St. Mary Magdalene will accept whatever portion of the forms you may care to share and keep them on file.
You can do yourself and your loved ones a favor by taking the time to complete this information.
TABLE OF CONTENTS
1. EMERGENCY CONTACT INFORMATION.. 3
2. Additional Emergency Contact Information.. 4
3. Health Care Professional Contact Information.. 6
4. Family AND Other Key Personal Contacts. 7
5. Business AND Financial Contacts. 9
6. Biographical Data for Death Certificate and Obituary.. 10
My Full Name
Address
City State Zip Code
Phone E-mail Address
Social Security Number
Date of Birth
Primary Health Insurer
(Medicare is considered primary)
Health Insurance Policy No.
Supplemental Insurer
Supplemental Insurance Policy No.
The first person to notify in case of emergency:
Name
Address
City State Zip Code
Daytime Phone Evening Phone
Relationship E-mail
Alternate contact in case of emergency:
Name
Address
City State Zip Code
Daytime Phone Evening Phone
Relationship E-mail
St. Mary Magdalene Episcopal Church or other congregation/parish church.
Church Name
Address
City State Zip Code
Daytime Phone Pastor
Healthcare surrogate to make healthcare and other personal decisions on your behalf.
Name
Address
City State Zip Code
Daytime Phone Evening Phone
Relationship E-mail
I have an Advance Directive for healthcare YES / NO Date signed
I have a Do Not Resuscitate order YES / NO Date signed
Financial Power of Attorney to make financial decisions on your behalf.
Name
Address
City State Zip Code
Daytime Phone Evening Phone
Relationship E-mail
I have a Financial Durable Power of Attorney YES / NO Date signed
Executor of Your Will or Trustee to carry out your wishes after your death.
Name
Address
City State Zip Code
Daytime Phone Evening Phone
Relationship E-mail
Attorney
Name
Address
City State Zip Code
Daytime Phone Evening Phone
Relationship E-mail
Other Emergency Contact
Name
Address
City State Zip Code
Daytime Phone Evening Phone
Relationship E-mail
Primary Care Physician/Provider
Name
Address
City State Zip Code
Daytime Phone E-mail
Area of Practice/Specialty
Other Physicians or Healthcare Professionals
Name
Address
City State Zip Code
Daytime Phone E-mail
Area of Practice/Specialty
Name
Address
City State Zip Code
Daytime Phone E-mail
Area of Practice/Specialty
Name
Address
City State Zip Code
Daytime Phone Evening Phone
Relationship E-mail
Name
Address
City State Zip Code
Daytime Phone Evening Phone
Relationship E-mail
Name
Address
City State Zip Code
Daytime Phone Evening Phone
Relationship E-mail
Name
Address
City State Zip Code
Daytime Phone Evening Phone
Relationship E-mail
Name
Address
City State Zip Code
Daytime Phone Evening Phone
Relationship E-mail
Name
Address
City State Zip Code
Daytime Phone Evening Phone
Relationship E-mail
Name
Address
City State Zip Code
Daytime Phone Evening Phone
Relationship E-mail
Name
Address
City State Zip Code
Daytime Phone Evening Phone
Relationship E-mail
Employer
Contact Person
Company
Address
City State Zip Code
Daytime Phone
Bank Accounts
Bank Name
Address
City State Zip Code
Daytime Phone Passwords_____________________________
Checking Account No.(s)
Savings Account No.
Contact Person
Other Financial Institutions (e.g. Broker, Life Insurance Company)
Institution/Relationship
Daytime Phone
Account No.(s)
Institution/Relationship
Daytime Phone
Account No.(s)
Your Birthplace
City State Country
Your Date of Birth
Your Parents
Your Father’s Full Name
Deceased? YES / NO
Birth date Birthplace
Occupation
Your Mother’s Full Name
Deceased? YES / NO
Birth date Birthplace
Occupation
Your Present Marital Status (circle)
Single, Married, Partnered, Widowed, Separated, Divorced
Date of ceremony Dissolution Date, if any
Name of Spouse/Partner
Birth Date Place of Birth
Date of Death
Spouse/Partner Occupation
Names of Children and Their Cities of Residence
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Brothers/Sisters and Cities of Residence
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Number of Grandchildren__________ Number of Great-Grandchildren___________
Schools You Attended and Degrees Earned
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Your Present Occupation
Name of Organization
Address
Present Position
Dates Employed
Previous Occupations
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Military Record (important in case of possible veterans’ benefits and/or burial)
Date Enlisted Rank
Branch of Service “C” Number
Date Discharged Service No
Veterans’ Organizations
Association Affiliations, Labor Unions, Political Offices Held, Club Memberships
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My Full Name
In the Episcopal tradition, it is customary for members to be buried from the church.
Yes, it is my desire that my funeral shall be held at St. Mary Magdalene, Silver Spring, MD
It is my desire that my funeral shall be held at the funeral home listed in Section 8 of this document.
It is my desire that my funeral shall be held at the church listed below, where the clergy in charge of said church shall arrange for the services.
Church Name
City State Phone
The Service
Liturgy Choices:
_____Rite 1 Traditional Language _____ Rite 2, Contemporary Language
_____Enriching Our Worship
Some of my favorite hymns and musical selections:
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Some of my favorite passages of Scripture, literature, etc.:
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Some of my favorite flowers and colors are:
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I would like to emphasis the following theme/message for framing the service:
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A Service in Thanksgiving for the Life of:
Your Name
Musical Prelude
I want Holy Communion as a part of this service: Yes / No
Gathering in God’s Name
Opening Hymn
Source No.
Liturgy of the Word
Hebrew Scripture
Psalm Epistle
Gradual Hymn / Solo / Anthem
Source No.
Gospel Reading
Departing in Peace
Closing Hymn
Source No.
Musical Postlude
Potential Participants in the Funeral Service
Clergy Assisting Clergy
Preacher
Acolytes
Pallbearers
Readers
Ushers
Musicians
Others whom I would like to participate
Name Role
Name Role
Name Role
Name Role
Name Role
Name Role
Other Miscellaneous Information Regarding My Funeral
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Funeral Home
Contact Person
Funeral Home
Address
City State Zip Code
Daytime Phone E-mail
I have prepaid arrangements I have made plans but have not prepaid
Final Disposition of My Body
Full body buried in a cemetery plot Location _____________________________ Cremation with burial in a cemetery plot Location_____________________________ Cremation ashes scattered (location)
Donation of entire body or organs
Name of Donor Organization
Address
City State Zip Code
Phone No. E-mail
Cemetery
Name of Cemetery
Address
City State Zip Code
Phone No. E-mail
Location of my will and trusts
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Location of securities, life insurance, etc., and/or name, address, phone no. of broker.
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Location of deed, mortgage agreement, lease, car title, etc.
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Location of papers concerning arrangements for organ donations
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Estimated number of copies of death certificate needed to process my estate (copies required for Social Security, VA, each insurance company, each bank account, every stock and/or bond, house and other properties).
Names of persons who have been given copies of sections of these forms (financial POA, health care, executors, funeral directors, parish church, family/friends).
Name Phone
Name Phone
Name Phone
Name Phone
Name Phone
List of websites and Passwords: (Consult agencies such as Facebook, twitter, etc. about how to terminate and/or change your on-line presence.)
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Other information that may be helpful to my survivors:
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