My Wishes

Record Keeper

UC8164_0714
To My Family

My goal is to make it easy as possible for you at what is probably

a difficult time. I know you have many decisions to make on my
behalf and I hope this information will help.

Thank you.

________________________ _____________
Signature Date
About Me
Marital Status
This is information about me that will help you in locating records and
in writing an obituary.
____ Married ____ Single ____ Divorced ____ Widowed
Full Name
Birth name (if different): _______________________________________
First: _______________ Middle: _____________ Last: ______________
Spouse’s name: _______________________________________________
Social Security Number: _______________________________________
Date and place of marriage: ____________________________________
Country of citizenship: ________________________________________
Parents
Address
Father’s name:_______________________________________________
Street: _______________City: ________________ State: _____________
Birthplace: __________________________________________________
ZIP: _________________At this address since (date): ________________
Mother’s birth name: __________________________________________
Birth
Birthplace: __________________________________________________
City: ______________________State: ____________________________
Military Record:
Date of birth: ___________________ Country: _____________________
Branch of Service: _________________ Serial Number: ______________
Work
Rank: _____________________________________________________
Occupation: ________________________________________________
Date and place of induction: ____________________________________
Date retired: ______________ Employer(s): ________________________
Date and place of discharge: ____________________________________
Retirement benefits from previous employer?: _______________________

Previous Employer: ___________________________________________

2 3
Education People to Contact

Insitution(s) Year(s) Degrees Earned Name: ______________________Phone number: ___________________

___________________ __________________ ________________ Address: _____________________Relationship: ____________________

___________________ __________________ ________________ Name: ______________________Phone number: ___________________

___________________ __________________ ________________ Address: _____________________Relationship: ____________________

Clubs and Organizations: _____________________________________ Name: ______________________Phone number: ___________________

__________________________________________________________ Address: _____________________Relationship: ____________________

Social Media Name: ______________________Phone number: ___________________

Social Media Platform Login Password Address: _____________________Relationship: ____________________

___________________ __________________ ________________

___________________ __________________ ________________

Digital Assets

Hardware: __________________________________________________

Online Accounts: _____________________________________________

Information or Data (photos, music, etc.): __________________________

__________________________________________________________

Domain Names: _____________________________________________

4 5
My Advisors My Finances

The people I sought for advice on important matters and their contact Information about some of my financial dealings.
information.
Banking
Name Phone
Checking Account(s):__________________________________________
Attorney: ____________________ ___________________
Institution(s):________________________________________________
Accountant: ____________________ ___________________
Savings Account(s): __________________________________________
Financial Advisor: ____________________ ___________________
Institution(s):________________________________________________
Insurance Agent: ____________________ ___________________
Investments
Physician: ____________________ ___________________
Investment Type:_____________________________________________
Employer Benefits: ____________________ ___________________
Account or Certificate Number:__________________________________
Other: ____________________ ___________________
Investment Type:_____________________________________________

Account or Certificate Number:__________________________________

Investment Type:_____________________________________________

Account or Certificate Number:__________________________________

Investment Type:_____________________________________________

Account or Certificate Number:__________________________________

6 7
Credit Cards Other Assets

Institution: _________________________________________________ Description: _________________________________________________

Account Number:_____________________________________________ Purchase Price and Date:_______________________________________

Institution: _________________________________________________ Location of Asset: ____________________________________________

Account Number:_____________________________________________ Insurance Coverages

Institution: _________________________________________________ Health: ____________________________________________________

Account Number:_____________________________________________ Life:_______________________________________________________

Loan Disability: __________________________________________________

Institution: _________________________________________________ Critical Illness: ______________________________________________

Account Number:_____________________________________________ Property and Casualty:_________________________________________

Institution: _________________________________________________ Long-term Care: _____________________________________________

Account Number:_____________________________________________

Real Estate

Owners: ___________________________________________________

Title Held as:________________________________________________

Purchase Price and Date: ______________________________________

8 9
My Important Documents
Automobile Titles: ____________________________________________

Location of the documents you may need to settle my affairs.

Birth Certificate: _____________________________________________

Safety Deposit Box Location: ____________________________________

Marriage License: ____________________________________________

Box Number______________Location of Keys: _____________________

Other: _____________________________________________________

Will: ______________________________________________________

Living Will: _________________________________________________

Medical Power of Attorney: _____________________________________

Financial Power of Attorney: ____________________________________

Trusts: _____________________________________________________

Social Security Card: __________________________________________

Military Records: _____________________________________________

Insurance Cards: _____________________________________________

Insurance Policies: ____________________________________________

Pensions & Retirement Plans: ___________________________________

Income Tax Documents: _______________________________________

Stocks and Bonds: ____________________________________________

Property Deeds or Mortgages: ___________________________________

Bank Records: _______________________________________________

10 11
My Memorial Service
Viewing: ___________________________________________________
Here are my wishes for my memorial service and final resting place.
Eulogy: ____________________________________________________
Funeral Home: _____________________________________________
__________________________________________________________
Pre-arrangements:: ____YES ____NO
Music: _____________________________________________________
Type of Service: ______________________________________________
__________________________________________________________
Desired Location: ____________________________________________
Prayers or Readings: __________________________________________
Religious Affiliation: __________________________________________
__________________________________________________________
Clergyman or Officiant: _______________________________________
Flowers: ____________________________________________________
Phone Number:______________________________________________
Donations: _________________________________________________
Pallbearers: _________________________________________________
Preferred Cemetery or Mausoleum: _______________________________
__________________________________________________________
Plot Purchased: ____YES ____NO
__________________________________________________________
Location: ___________________________________________________
__________________________________________________________
Headstone or Monument: ______________________________________
__________________________________________________________
Inscription: ____________________________________
__________________________________________________________
__________________________________________________________
Speacial Requests
Special Request Instructions: ____________________________________
Clothing: ___________________________________________________
__________________________________________________________
__________________________________________________________

12 13
One Last Wish
My Travels: _________________________________________________
This is what I would like my family and friends to remember about me.
__________________________________________________________
My Early Life: _______________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
My Favorite Places: ___________________________________________
__________________________________________________________
__________________________________________________________
My Hopes and Dreams: ________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
My Greatest Accomplishments: __________________________________
__________________________________________________________
__________________________________________________________
My Career: _________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
My Fondest Memories: ________________________________________
__________________________________________________________
__________________________________________________________
My Hobbies and Interests: ______________________________________
My Family History: ___________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

14 15
Final Thoughts and Instructions

Here are a few more things I’d like for you to know.

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16
 Courtesy of
Mutual of Omaha Insurance Company

[Agent/Marketer Name]
[Agent/Marketer Phone Number]
[Agent/Marketer Email Address]