Survey

For more information on
organ/tissue donation www.organdonor.gov
www.donatelifeindiana.org

Name:
Address:
City:
State:
Zipcode:
Phone:
Email:
Preferred Contact Method:
Best Time To Reach You:
What is your current age?:
Are you currently:
Have you ever been responsible for making funeral arrangements?:
If you have given any thought to the subject, which of the following would you choose for yourself?:
How much might you expect to pay for a funeral:
Do you maintain up-to-date biographical information and accurate family records to assist with funeral planning?:
Have you made final plans and arrangements for cemetery property?:
Have you made final plans and arrangements for the type of services you desire?:
Are you aware that a prearranged funeral plan may help you qualify for medicaid?:
Are your loved ones aware of what you prefer for your own arrangements?:
Would it give you peace of mind to plan in advance to spare your family the burden?:

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