John J. Bryers Funeral Home, Inc.

406 North Easton Road

Willow Grove, Pennsylvania 19090

(215) 659 – 1630

Fax 215-659-4517

Email: bryersfh@yahoo.com

Jeffrey S. Thompson-Supervisor

Please fill in form and mail or fax back to 215-659-4517. A copy of your information will be kept on file.

A Card will also be sent out as a confirmation.

Name:___________________________________________________________

Address:_________________________________________________________

Date of Birth:_____________________ Place of Birth:_____________________

Social Security #:_________________ Marital Status:____________________

Name of Spouse:__________________________________________________

Occupation During Working Career:____________________________________

Employer During Working Career:_____________________________________

Father’s Name:____________________________________________________

Mother’s Name Including Maiden Name:________________________________

Highest Level of Education Completed:_________________________________

Are you a Veteran:___________ Branch of Service_______________________

Veteran Service #:_____________Do You Have Your Discharge Papers_______

Church Affiliation____________________________

Cemetery Information:______________________________________________

Children:_________________________________________________________

# of Grandchildren:_____ # of Great Grandchildren:_____

Additional Information for Newspaper Notice:___________________________

_______________________________________________________________

Funeral Requested Please Circle: Traditional Funeral with Burial, Burial Only

Direct Cremation, Viewing Followed by Cremation, or Cremation with Memorial