My Funeral Wishes -  login to update details

Please Complete this form to give us a record of your funeral wishes.

You will be able to login and change them in future should you wish to do so.

Please note your wishes are confidential and may be updated at any time. Please complete the following fields and add any details you feel appropriate.

Password (please make a note of this so you can login and make amendedments in future)
email (please also make a note of this so you can login and make amendedments in future)
Christian Name(s)
Post Code
Telephone number
Date of Birth
In the event of my death I wish to be BURIED / CREMATED at
If Burial in an existing grave then Grave number
If Cremation then final destination of ashes
Owner of Grave
Service to take place at
Hymns 1
Hymns 2
Hymns 3
Other Music choices
Donations to Charity in your memory
Choice of Flowers
Funeral to commence from
Number of Limousines required1 (each seat seven)
Traditional Jaguar (tick if required1)
Horsedrawn (tick if required1)
Other (please specify)
Wood veneered (tick if required1)
Solid Oak (tick if required1)
Cardboard (tick if required1)
ECO Willow (tick if required1)
Other (please specify)
Viewing (tick if required1)
Bearers Names (seperated by commas)
Venue for after funeral Reception
Next of Kin
Any further Information
Anti Spam Question
Please Type the characters in red into the box on the right

If you would like to discuss your requirements please...

© David H.Smith Funeral Directors, Registed Office: Leek, Company Number: 04247467