Gary L. Rollins Funeral Home | Frederick, MD Funeral Home & Cremation

Your information

First Name:

Last Name:

Phone:

Email:

This plan is for...

First Name:

Middle Name:

Last Name:

Gender:

Male
Female

Birth Date:

Birth Place:

Family information

Marital Status

Married
Single
Widowed

Name of Spouse:

Maiden Name of Spouse (if applicable):

Marriage Date:

If deceased, date of death:

Father's Name:

Address (if living):

City:

State:

Zip/Postal Code:

Mother's Name:

Address (if living):

City:

State:

Zip/Postal Code:

Siblings (living):

Siblings (deceased):

Children (living):

Children (deceased):

Grandchildren (living):

Grandchildren (deceased):

Great Grandchildren (living):

Great Grandchildren (deceased):

Education & Work

Highest Level of Education:

School Name:

School Location:

Occupation:

Company:

Years at Company:

Military Service

Yes
No

Branch of Service:

Years Served:

Visitation Options

Visitation at funeral home.
Visitation at:
I do not wish to have visitation hours.

Funeral Service Options

Funeral service at funeral home.
Funeral service at:
I do not wish to have a funeral service.

Reception Options

Reception at funeral home.
Reception at:
I do not wish to have a reception.

Burial or Cremation

Burial
Cremation

Final Disposition

Ground Interment (burial)
Mausoleum Entombment (above ground burial)
Columbarium (for cremation urns)
Ashes returned to family

Graveside/Committal Service

Yes
No

Service Requests

Please list any musical selections you would like to include in your services.

Please list any poems, religious texts, or readings you would like to be read at your services.

Please list any interests or hobbies you would like to include into your services.

Please list any special themes you would like to include into your services.

Please list any specific foods or beverages you would like to make available to your family and guests at the services.

Is there a special story, personal thank you, or message of hope you would like to be read during your services?

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