Life Crisis Form
In Case of Life Threatening Illness or Death
This form is provided to have significant information conveniently
available. It is wise to discuss this information with your
family, give a copy to your next of kin, and keep a copy for
your personal file. Update it anytime you wish. The Church
of the Larger Fellowship would like to be informed of any
life crisis of our members.
Name ____________________________________________
Address __________________________________________ Phone
_______________
Birth date ___________ Birth place _____________ Social Security
Number ____________
 Single
Married
Coupled
Divorced
Widowed
Name of Spouse or Partner ___________________ Spouse's Social
Security No. _______
Veteran - U.S. Armed Forces Number ___________________
Father's Name _____________________ Birthplace _________________________
Mother's Maiden Name _____________________ Birthplace __________________
Children (Please give their names and birth dates, plus address
and phone number if no longer living with you):
Close Relatives (Names, addresses and phone numbers):
Close friends who can help in a time of crisis (Names, addresses
and phone numbers):
Doctor's name and phone: __________________________________________
Dentist's name and phone: __________________________________________
Attorney's name and phone: ________________________________________
Date: __________ Signature: __________________________________
Space for additional information & comments:
Do you have a Durable Power of Attorney for Health Care?
YesNo
If so, who is your primary agent? ___________________________________
Who is your alternate? ___________________________________________
Have you executed a Declaration of your wishes regarding
extraordinary treatment in case of life threatening illness?
YesNo
If so, where is it located? ____________________________________
Does your physician have a copy? Yes No
Do you wish to donate organs at time of death? YesNo
If yes, where is your organ donation form located? ____________________________
Do you have a will or living trust? YesNo Not applicable
If yes, where is it located? ________________________________________________
Have Guardian(s) been selected for your minor children in
the event of death of both parents?
YesNo Not applicable
If yes, give their name, address and phone: __________________________________
Do you belong to a funeral or memorial society? YesNo
If so. which one? ______________________________________________
Which death arrangements do you wish? Burial Funeral
(with casket or ashes present)
Cremation Memorial Service (where?) ____________________________
Your chosen location for burial, or the storing or
scattering of ashes:
Who do you wish to have in charge of after-death details?
Things to be sure are included in the service (thoughts, readings,
music):
Preference for a minister to conduct the service: Other people
I would like to take part in the service:
To what organizations or causes would you appreciate gifts
in your memory to be given?
Please consider making a gift to the Church of the Larger
Fellowship.
Please notify my church, the Church of the Larger Fellowship
25 Beacon St, Boston, MA 02108 617/ 948-6166 info@clfuu.org
Last updated June 12, 2005
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