https://smithfamilymortuaries.efuneral.com/

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Vital Information

Full Name:

Date of Death:

Address:

Telephone Number:

Email Address:

Date of Birth:

City and Province of Birth:

Father's Name:

Father's City of Residence:

Mother's Name:

Mother's City of Residence:

Mother's Maiden Name:

Spouse's Name:

Spouse's Maiden Name:

Survivors' Names and Cities of Residence:

Relatives Who Have Preceded In Death:

Occupation:

Business Type:

Company Name:

Church Membership:

Lodge or Union Name:

Veteran:

Branch of Service:

Serial Number:

Date Enlisted:

Date of Discharge:

Rank at Discharge:

Location of a Copy of Discharge (DD214):

Time of Military Service:

Military Honors at Graveside:

Flag Preference for Service:

Type of Service:

Visitation Hours:

Casket:

Person in Charge of Arrangements:

Officiating Clergy:

Pallbearers:

Flower Preference:

Music Selection:

Jewelry:

Glasses:

Casket Preference:

Disposition:

Outer Container Preference (for ground burial):

Cemetery Name:

Cemetery Location:

The Cemetery Property is in the Name of:

Miscellaneous Notes and Instructions:

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Smith Family Mortuaries

1415 North Rock Rd • Derby, Kansas

316-788-2828

316-788-2829

Culbertson-Smith Mortuary

115 South Seneca • Wichita, Kansas

Phone 316-265-2646

Fax: 316-265-2669

Smith Mortuary - Haysville Chapel

7031 South Broadway • Haysville, Kansas

Phone: 316-522-7553

Fax: 316-788-2829

Smith Mortuary - Mulvane Chapel

501 SE Louis Blvd. • Mulvane, Kansas

Phone: 316-777-1632

Fax: 316-788-2829

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