Consigli-Ruggerio Funeral Home
Information Form

Name: First: _______________ Middle: _______________ Last: _______________

Residence: __________________________________________

Phone: __________________________________________

Sex: _____ Ethnicity: _____ Single: _____ Married: _____ Widowed: _____ Divorced: _____

Husband of (Maiden Name): __________________________________________

Wife of: __________________________________________

History of Residence: __________________________________________

Birthplace of Deceased - City: __________________________________________

Date of Birth: Month: ________ Day: _____ Year: _______

Age: _____ Years: _____ Months: _____ Days: _____

If Veteran, specify War & Company: __________________________________________

Occupation: ______________________ Social Security: ______________________

Kind of Business: ______________________ Company: ______________________

Years Employed: ______________________ Retired: ______________________

Education Level: __________________________________________

Informant: __________________________________________

Phone: __________________________________________

Informant's Address: __________________________________________

Father's Name: __________________________________________

Father's Birthplace: __________________________________________

Mother's Maiden Name: __________________________________________

Mother's Birthplace: __________________________________________

Cemetery/Crematory: __________________________________________

City or Town: __________________________________________

Funeral at: __________________________________________

Date: __________ Hour: __________ A.M. - P.M.

Calling Hours: __________________________________________

MILITARY SERVICE

Entering Date: __________________________________________

Discharge Date: __________________________________________

Service Number: __________________________________________

Rank, Rating: __________________________________________

Organization/Outfit: __________________________________________

SURVIVING RELATIVES AND ADDRESSES

Father: __________________________________________

Mother: __________________________________________

Husband: __________________________________________

Wife: __________________________________________

Sons:
__________________________________________
__________________________________________
__________________________________________

Daughters:
__________________________________________
__________________________________________
__________________________________________

Brothers:
__________________________________________
__________________________________________
__________________________________________

Sisters:
__________________________________________
__________________________________________
__________________________________________

Grandchildren (No.): _____ Great Grandchildren (No.): _____

Newspapers:
___ Milford Daily
___ WMRC
___ Middlesex
___ Worcester Telegram & Gazette
___ Woonsocket Call
___ Blackstone Valley Tribune
___ Boston Herald
___ Boston Globe
___ Other: _________________
___ Picture for Newspaper
Memorial Donations:
__________________________________________
__________________________________________

SERVICE DETAILS

Clergyman: ___________________________ Call for: _______________

Church:
__________________________________________
__________________________________________

Bearers:
__________________________________________
__________________________________________
__________________________________________

Education:
__________________________________________
__________________________________________

Wedding Anniversary: __________________________________________

Orders & Societies:
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________

Music:
__________________________________________
__________________________________________
__________________________________________

CEMETERY INFORMATION

Grave No.: __________ Plot No.: __________

Range No.: __________ Section No.: __________

Lot Owner: __________________________________________

Please return this form via mail or fax to:

Consigli-Ruggerio Funeral Home, Inc.
46 Water Street
Milford, MA 01757
Telephone: 508-473-0513
Toll Free: 800-675-0513
Fax: 508-634-3662