3661 E. French Camp Road

Manteca, CA 95336

Phone: 209-982-1611

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Full Name:

Gender:

Residence Address:

City:

State:

Zip Code:

Phone:

Email:

Date of Death:

Place of Death:

Date of Birth:

Place of Birth:

Social Security Number:

Marital Status:

Surviving Spouse (Maiden Name):

Date of Marriage:

Place of Marriage:

Father's Name:

Mother's Name (Maiden Name(:

Additional Family Members:

Highest Education:

Grade School

High School

Degree

Master Degree

Doctorate

Occupation:

Company Name:

Business Field:

U.S. Armed Forces Member:

Yes

No

Branch of Service:

Serial Number:

Date Entered Service:

Rank at Discharge:

New Field:

Discharge on file at:

Do you have a copy of your discharge papers?

Yes

No

Wars Fought In?

Place of Service Request:

Funeral Home

Church

Cemetery

Name of Church or Cemetery:

Place of Visitation:

Religious Denomination:

Place of Worship:

Lodge/Union/Assoc. Membership:

Person in charge of final arranagements:

Disposition Request:

Earth Burial

Mausoleum

Cremation

Other

Cemetery:

Lot #:

Section/Letter:

Grave #:

Address:

Telephone:

Additional Instructions:

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Proudly Serving the Communities of Stockton, Manteca, Modesto, Lathrop, French Camp, Ripon, Lodi, and all of the San Joaquin Valley.

209-982-1611

3661 E. French Camp Road Manteca, CA 95336

Email: info@parkviewmortuary.com

FD-1360

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