End-of-Life Plans & Wishes Form
Please complete this page so that the Death and Memorials Committee has your emergency contact information. Page four has additional information regarding your end-of-life wishes. Please complete the second page if you would like the Death and Memorials Committee to also keep this information. Be sure to keep a copy for your own records in a place that your family or friends can easily access.
Member/Attender Name: __________________________________________________
Home Address: __________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Phones: home: ________________ work: _______________ cell: __________________
Email____________________________________
Emergency contacts in the event of serious injury/illness, death or impending death:
First Choice Name: _______________________________________________________
Address: _______________________________________________________________
_______________________________________________________________________
Phones: home: _______________ work: ________________ cell: _________________
Email: ____________________________________
Second Choice Name: _____________________________________________________
Address: ________________________________________________________________
________________________________________________________________________
Phones: home: _______________work:________________cell:____________________
Email: ________________________________________
Signature__________________________________________Date__________________
Please return to a committee member or mail to:
Mountain View Friends Meeting
Death and Memorials Committee
2280 S. Columbine St.
Denver, CO 80210
I have:
- a will: ?yes ?no located at/with_________________________________
- advanced directives: ?yes ?no located at/with____________________
- burial/cremation arrangements: ?yes ?no located at/with _________________________________________________________________
- all necessary arrangements completed for end-of-life: ?yes ?no located at/with___________________________________________________________
Additional Records (give location of record, or name, address, phone no of who has it):
Durable Power of Attorney_________________________________________________
_______________________________________________________________________
Medical Power of Attorney_________________________________________________
_______________________________________________________________________
Your Attorney____________________________________________________________
________________________________________________________________________
Your Physician___________________________________________________________
________________________________________________________________________
Health Insurance__________________________________________________________
________________________________________________________________________
Preferred Hospital ________________________________________________________
________________________________________________________________________
Location of important papers________________________________________________
________________________________________________________________________
Burial arrangements/cemetery/crematory_______________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Specific instructions:
I would like a memorial service ?yes ?no
Please type or print clearly any special wishes for this gathering or attach additional information if you wish:
Signature__________________________________________Date__________________
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