Moeller Funeral Home
104 Roosevelt Road
Valparaiso, IN  46383
(219) 462-0535
 Kosanke Funeral Home
105 East Indiana Avenue
Kouts, IN  46347
(219) 766-2224

Wanatah Funeral Chapel
309 North Main Street
Wanatah, IN  46390
(219) 733-2313
 Angelcrest Cemetery
Highway 49 and 600 North
Valparaiso, IN  46383
(219) 531-8690

Pre-Arrangement / At-Need Information
The information in the first three sections are needed to complete a death certificate.  However,  it is not necessary to complete every box at this time if you're uncomfortable about sending certain information over e-mail.  We can get the remaining information at a later time.  You may also Print this Form and mail or fax it to us at:  104 Roosevelt Road- Valparaiso, IN  46383    Fax:  (219) 464-9582
We recommend when you have finished completing this form that you Print a Copy in case of any transmitting errors and to keep for your records.
Personal Information
First Name : Last Name :  
Middle Name :   Social Security # :  
Date Of Birth(mm/dd/yyyy) : Place Of Birth :  
Home Address :   City :  
Country :   State :  
ZipCode :   HomePhone :  
Work Phone :   Email :
Father's Name :   Mother's Name :  
Mother's Maiden Name :   Marital Status :  
Spouse's Name :   Spouse's Maiden :  
Date Of Marriage(mm/dd/yyyy): Place Of Marriage :  
Work/Education History
Work/Education History
Eduction(0-12) :   College(0-5+) :  
Occupation/Title :        
Employer (Primary) :   Employer (Secondary) :  
Type Of Business :   Type Of Business :  
Years Employed :   Years Employed :  
Year Retired :   Year Retired :  
Military Record
Branch Of Service :   Serial Number :  
Date Enlisted (mm/dd/yyyy): Rank at Discharge :  
Date Discharge(mm/dd/yyyy) : Discharge On File At :  
Copy Of Discharge Paper :  
Name Of Wars :  
Informant  (Only if different than person listed above)
Name :   RelationShip :  
Address :   City/State/Zip :  
Home Phone :   Work Phone :  
Email :  
Are you the Legal Next-To-Kin or P-O-A ? :    
Type of Service and Merchandise Request
Type Of Service :  
Casket / Urn        
Vault        
Funeral Service Request
Funeral Home :        
Place Of Visitation :  
Place Of Service :  
Religious Denomination :  
Place Of Worship :  
Lodge/Union :  
Person(s) in Charge of Final Arrangements:  
Special Instructions
Special Instruction
Flower Preference :  
Music :  
Jewelry :  
Glasses :  
Clothing :  
Casket Bearers :
1.
2.
3.
4.
5.
6.
 
Others :  
Disposition Request
I Already Have Cemetery Spaces:
If "Yes" Cemetery Name:    
City : State: Zip:
Phone : Section: Lot#:
Grave #: Is There a Monument In Place?
If "No" I Prefer: Cemetery Preference:
City: State: Phone:
Other Instructions
Memorials Donations
Please Select One or More of the Options Below