Vital Statistical and Biographical Record

We suggest completing the following record and filing a copy of this information with the Borek Jennings Funeral Home. In the event of death, this information will be extremely helpful. There is no cost involved in doing this.

Full Name:____________________________________________________________________________

Address:_____________________________ City, Township & State:____________________________

Phone:_______________________________

Marital Status:__________________ Spouse:___________ If Female Maiden Name:_______________

Date of Marriage:________________ Place of Marriage:_______________________________________

Birth Date:________________ Birthplace:_______________ Ethnic Origin:________________________

Fathers Name:__________________________ Mothers Name:_________________________________

Length of Residence Here:___________________ Education:___________________________________

Usual Occupation:_____________________ Employer:__________________ Retirement:____________

Social Security Number:________________ Veteran:__________ Branch of Service:________________

Religious Affiliation:_____________________________ Church:_________________________________

Clubs/Organizations:____________________________________________________________________

_____________________________________________________________________________________

List of Family Members: (Spouse, children, brothers, sisters)

Example: John (wife's first name) Smith, Son - Smithville, Michigan

Name: Relationship City/State

_____________________________________________________________________________________

Number of Grandchildren:__________________________ Great Grandchildren:____________________

Proceeded in Death by:_________________________________________________________________