602 No. Spruce St. - Ogallala, Nebraska 69153 - 308-284-4055
Randy Gubser - Director

Being prepared not only gives you piece of mind but also removes any questions during a time of loss.  This is a guide to help you prepare for funeral arrangements.  Please complete the form.  Contact us with any questions or concerns.

  Gubser Funeral Home - Ogallala & Keith County, Nebraska
 
Name of the person filling out this form (First Last):
Your phone number:
Your email:
I am planning for

Personal Information

Full Name (First Middle Last):
Gender:
Marital Status
Address:
City:
County:
State:
Zip:
Phone:
Social Security Number:
Date of Birth: (mm/dd/yyyy)
Place Of Birth:
Spouse's Name:
Spouse's Maiden Name:
Place of Marriage:
Date of Marriage: (mm/dd/yyyy)
Place of Marriage:
Father's Name:
Mother's Maiden Name:

Current surviving family (information will be updated at the time of death):

Preceded in death by:

Employment & Education History

Education Level: Primary:
  Secondary:
Occupation:
Employed by:
# Of Years:
Retired in:

Military Service

Service Branch:
Date Enlisted: (mm/dd/yyyy)
Date Discharged: (mm/dd/yyyy)
Rank At Discharge:
Discharge On File At:
Location of my discharge:
Name of any wars served in:

Funeral Preferences

I Prefer My Funeral Service To Be:
Place Of Service:
Religious Denomination:
Place Of Worship:
Worship leader:
Name of worship leader:
Casket Bearers (6): 1.
  2.
  3.
  4.
  5.
  6.

Memorialization Instructions
Musical Selections
To Be Played:		 1.
  2.
  3.
  4.
  Will Supply CD/Tape
Musical Selections
To Be Sung:		 1.
 (usually use two selections) 2.
  3.
  4.
Favorite Bible Passages:
Favorite Literature or Poems:
Favorite Flower(s):
Favorite Flower Color:
Please list any memorials or donations to charity that you would like:

Final Disposition

Preference for final disposition is (check one): Ground interment with
  Mausoleum
  Cremation with
Preference of cemetery:
Address of cemetery:
Check if a cemetery plot is owned at the above location

Special Instructions

Person to Finalize Arrangements at Time of Death

Name:
Relationship:
Address:
City:
State:
Zip:
Phone:
E-mail:

Send me information on pre-arrangement
 Contact me to set an appointment
 Keep my information on file