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Willis Funeral Home

Gallipolis, Ohio 45631
Phone: (740) 446-9295
Fax: (740) 446-4990
Contact us with questions and comments
Web Site: www.willisfuneralhome.com

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Step 1 Biographical Information


Step 2 Arrangement Information

Full Name
(First MI Last):
Marital Status: Social Security#:
Date of Birth: Place Of Birth:
Address:
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County: Zip:
Phone: E-mail:
Spouse's Name: Spouse's Maiden Name:
Place of
Marriage: 		Date of Marriage:
Father's Name: Mother's Name:
Mother's Maiden Name:

Work/Education History
Education(0-12): College 1-5+:
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Business: Company:

Military Record
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Copy of Discharge Papers:    Yes    No
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Person in Charge:
Address:
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Insurance Information: