 |
15 Grove Street N.
Attleboro, MA 0276 |
|
|
Required Data and File Form Please print and fill out all fields that apply along with the Cremation Form (if applicable) and return by mail /fax or in person to Sperry & McHoul Funeral Home. |
||
|
Applicant's
name__________________ _________________ ____________________ Sex ______________ Telephone ______________________________ Residence street and number ________________________________________________ City/town _________________________________ State _________ Zip ____________ Race __________________ Date of birth ____ / ____ /____ Birthplace (city and state or foreign country) ________________________________________ Married, never married, widowed, or divorced __________________________________ Last spouse (if wife give maiden name) ___________________________________________ Usual Occupation (prior if retired) ______________________________________________ Kind of business or industry ________________________________________________ Social security number _____________________________ If U.S. war veteran specify war _______________________________________________ Father - full name _________________________________________________________ Father's state of birth (if not in U.S.A. name country) __________________________________ Mother - full name (Maiden) __________________________________________________ Mother's state of birth (if no in U.S.A. name country) __________________________________ Responsible survivor - name and mailing address ________________________________ ________________________________________________________________________ Telephone number _______________________ Relationship ______________________ Of hispanic origin? (if yes, specify Puerto Rican, Dominican, Cuban, etc.) yes_____ no_____ specify _________________________________________________ Education (highest grade completed) Elem/Sec (0-12) _____ College 1-4; 5+ _____ FOR VETERANS USE ONLY* Date of entering military service ____ / ____ / ____ Place _________________________ Date of discharge ____ / ____ / ____ Place __________________________________ Rank, rating __________________________ Service Number ______________________ Organization and outfit _____________________________________________________ *Veterans, include photocopy of Discharge Certificate List other survivors and/or obituary information on a separate sheet.
|