Please print, complete and return to your funeral home
(Provided as a courtesy of Lippert-Olson Funeral Home)
Items in Blue Bold are necessary for Wisconsin Death Certificate
Name__________________________________________________________(First, Middle & Last)
Address _________________________________________________________________________
City_________________________________State_______________ Zip Code_______________
Year moved to City_____________ Moved From_________________________________________
Birthdate_________________________ Birth Place_____________________________________
Marital Status_________Spouse's Name______________________(First, Middle & Last Name Prior to any Marriages)
Spouse Social Security Number___________________Spouse Birthdate_______________________
When Married________________ Where Married_________________________________________
Father's Name____________________________________________________(First, Middle & Last)
Mother's Name ____________________________________________(First, Middle & Last Name Prior to any Marriages & Last Name)
Social Security Number_________________________________Military Service Y______ N_____
Branch of Service________________________________________War________________________
Rank_______________ Where Served or Stationed_________________________________________
Discharge Papers Filed at ________________________________Veteran's Disability Y_____ N ____
Years of Education Completed Primary (1-12)_________ Secondary (College 1-6)_______
Schools & Colleges Attended___________________________________________________________
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Current or Last Occupation__________________________________________________________
Current or Last Employer______________________________________________________________
Years Employed________________________Date of Retirement______________________________
Previous Employment________________________________________________________________
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Religious Affiliation_______________________ Church Membership__________________________
Church Groups_____________________________________________________________________
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Memberships in Clubs, Lodges, Fraternal Orders, Civic Groups, Unions, Professional Organizations, etc.
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Hobbies and Other Interests___________________________________________________________
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Children (List oldest to youngest, please include spouse) & list City & State of Residence
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Number of Grandchildren______Great-grandchildren_________Great-great-grandchildren__________
Names of Grandchildren & Great-grandchildren
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Brother & Sisters (List oldest to youngest, including spouse) & list City & State of Residence
_________________________________________________________________________________
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Name of Person in Charge ____________________________________________________________
Address, City, State & Zipcode _______________________________________________________
Phone & Cell_____________________________________________________________________
Type of Service Selected: Traditional (Visitation in Evening-Funeral Ceremony Next Day___________
Contemporary Service: Visitation & Funeral Ceremony Same Day_____________________________
Place of Service: Funeral Home________ Church________ Name of Church____________________
Memorial Service____at Funeral Home _____or At Church (Name)____________________________
No Services____________
Type of Disposition: Burial _____ Entombment_______ Cremation_______ Body Donation________
Name & Location of Cemetery/Mausoleum_____________________________________________
Description of Lot or Mausoleum Space_________________________________________________
Comments (This space is provided for any additional items not covered above such as, musical selections
memorial funds to be established, special readings, additional newspapers for obituary placement, etc...)
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Preplanning and Prefunding Information
"My Wishes" Preplanning Booklet