Medical and final Wishes action Checklists...227 Chapter 10: Medical and final Wishes action...
Transcript of Medical and final Wishes action Checklists...227 Chapter 10: Medical and final Wishes action...
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Medical and final Wishes action Checklists
The checklists in Chapter 10 are set out in the following order:
• Burial• CelebrationofLife• Charities• Cremation• DonationofOrgansandTissues• Entombment• EthicalWill/LegacyDocuments• FinalWishes• Funeral• HealthCareDirectives• ItemstoDestroy• LetterstoFriendsandRelatives• Memorial Service• Obituary• PeopletoContact• PetCare• VeteransBurialBenefits• WholeBodyDonation• FinalWishes:Other
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Checklist for My Family: A Guide to My History, Financial Plans, and Final Wishes
© American Bar Association
burial
□ I do not wish to be buried.
□ I wish to be buried.
□ I do not own a cemetery lot.
□ I own a cemetery lot.
The ownership of the cemetery lot is in the name of: ______________________________
The lot is located at:
Cemetery: _______________________________________________________________
Section: _____________________________ Lot: ________________________________
Address: ________________________________________________________________
________________________________________________________________________
Other description:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Location of deed: _________________________________________________________
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□ I would like to have a grave marker.
□ I would like to have a grave marker furnished by the Department of Veterans Affairs.
□ I would like to have a service medallion furnished by the Department of Veterans Affairs.
I would like the following words to be placed on grave marker:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I would like the following type of casket:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Other burial instructions:
________________________________________________________________________
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Checklist for My Family: A Guide to My History, Financial Plans, and Final Wishes
© American Bar Association
Celebration of life
□ I do not want a celebration of life ceremony.
□ I want a celebration of life ceremony.
□ I have made prearrangements for a celebration of life ceremony.
Type of celebration: _______________________________________________________
People to invite:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Arrangement details:
Place: __________________________________________________________________
Time: ___________________________________________________________________
Food or beverage suggestions:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Entertainment or music suggestions:
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________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
□ I have created music for the celebration.
□ I have created a video for the celebration.
□ I have created photos for the celebration.
□ I have other requests for the celebration:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Notes for music:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Notes for photos:
________________________________________________________________________
________________________________________________________________________
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Notes for video:
________________________________________________________________________
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Checklist for My Family: A Guide to My History, Financial Plans, and Final Wishes
© American Bar Association
Charities
□ I do not want any memorial donations or gifts to charities.
□ I would appreciate memorial donations or gifts to the following charities:
Charity name: ____________________________________________________________
Contact information: _______________________________________________________
Website: _________________________________________________________________
Significance to me: ________________________________________________________
Charity name: ____________________________________________________________
Contact information: _______________________________________________________
Website: _________________________________________________________________
Significance to me: ________________________________________________________
Charity name: ____________________________________________________________
Contact information: _______________________________________________________
Website: _________________________________________________________________
Significance to me: ________________________________________________________
Charity name: ____________________________________________________________
Contact information: _______________________________________________________
Website: _________________________________________________________________
Significance to me: ________________________________________________________
Charity name: ____________________________________________________________
Contact information: _______________________________________________________
Website: _________________________________________________________________
Significance to me: ________________________________________________________
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Cremation
□ I do not want my body to be cremated.
□ I want my body to be cremated.
□ I want my body to be cremated followed by a memorial service.
□ I want my body to be cremated followed by a celebration of life service.
Following my cremation, I wish my ashes to be disbursed as follows:
□ To be scattered:
________________________________________________________________
□ To be placed in an urn and buried or entombed:
________________________________________________________________
□ Other:
________________________________________________________________
□ To be handled as my family sees fit.
********
□ I have not made prearrangements for my cremation.
□ I have made the following prearrangements for my cremation:
Company: _______________________________________________________________
Address: ________________________________________________________________
________________________________________________________________________
Phone: ______________________________ Website: ____________________________
The contract is located: _____________________________________________________
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© American Bar Association
Donation of organs and Tissues
□ I do not wish to donate any organs or tissues.
□ I wish to donate any needed organs or tissues.
□ My blood type is: _________________
□ I wish to donate only the following organs or tissues:
Organs:
□ Heart
□ Kidneys
□ Liver
□ Lungs
□ Pancreas
□ Other_________________
Tissues:
□ Blood vessels
□ Bone
□ Cartilage
□ Corneas
□ Heart valves
□ Inner ear
□ Intestines
□ Skin
□ Other _________________
*******
□ I have not prepared a uniform donor card.
□ I have a uniform donor card.
□ I have registered with my state’s organ donation registry at this website: ______________________________________________________
□ My uniform donor card is located: _____________________________________
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entombment
□ I do not wish to be entombed.
□ I want to be entombed.
□ I do not own a crypt.
□ I own the following crypt:
The ownership of the crypt is in the name of: ___________________________________
The crypt is located at:
Church/Mausoleum/Columbarium: ___________________________________________
Address: ________________________________________________________________
________________________________________________________________________
Space #: _________________________________________________________________
Other description:
________________________________________________________________________
________________________________________________________________________
Location of deed: _________________________________________________________
I would like the following words to be placed on the crypt:
________________________________________________________________________
________________________________________________________________________
Other instructions:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Checklist for My Family: A Guide to My History, Financial Plans, and Final Wishes
© American Bar Association
ethical Will/legacy Documents
□ I have not created any legacy documents.
□ I have created an ethical will.
□ I have created the following legacy documents:
Ethical will:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Books:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Pamphlets:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Videos:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Other:
________________________________________________________________________
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________________________________________________________________________
Please distribute them as follows:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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final Wishes
I wish to:
□ Be embalmed
□ Be an organ donor (see the Donation of Organs and Tissues Checklist)
□ Have my body bequeathed to a medical school (see the Whole Body Donation Checklist)
□ Have my body buried in the earth (see the Burial Checklist)
□ Have my body entombed in a mausoleum (see the Entombment Checklist)
□ Be cremated (see the Cremation Checklist)
□ Other: ________________________________
********
I wish to have:
□ A funeral service (body present) (see the Funeral Checklist)
□ A memorial service (body not present) (see the Memorial Service Checklist)
□ A celebration of life service
□ No service
□ A graveside service
□ I would like a U.S. flag covering my coffin
□ I would like to have military funeral honors
□ Other: ______________________________
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My preferences are as follows:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Checklist for My Family: A Guide to My History, Financial Plans, and Final Wishes
© American Bar Association
funeral
□ I do not want a funeral.
□ I want a funeral.
□ I have not made funeral prearrangements.
□ I have a pre-need contract and have pre-paid for some or all of my funeral.
□ I have made the following prearrangements:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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________________________________________________________________________
The pre-need contract is located: _____________________________________________
I wish the service to be for:
□ Friends and relatives
□ Private
□ Other: _________________________________
I wish the casket to be:
□ Closed
□ Open
□ I prefer to wear: ___________________________
Funeral establishment: _____________________________________________________
Address: ________________________________________________________________
________________________________________________________________________
Phone: __________________________Email: __________________________________
House of worship:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Religious leader/Officiant/Clergy:
________________________________________________________________________
________________________________________________________________________
Speakers/Readers:
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________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Ushers/Pallbearers:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Favorite scripture, psalms, poems, readings:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Special hymns, music, musicians, soloists:
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Checklist for My Family: A Guide to My History, Financial Plans, and Final Wishes
© American Bar Association
Health Care Directives
□ I do not have a durable power of attorney for health care.
□ I have a durable power of attorney for health care.
□ I have talked with my health care agent about my medical preferences.
□ I do not have a living will.
□ I have a living will.
Health care agent’s name: ___________________________________________________
Phone: ______________________________ Email: ______________________________
Address: ________________________________________________________________
________________________________________________________________________
□ I have given copies of my health care directives to the following:
Health care agent: _________________________________________________________
Physician: _______________________________________________________________
Physician: _______________________________________________________________
Physician: _______________________________________________________________
Hospital: ________________________________________________________________
Home health care agency: ___________________________________________________
Residential care facility: ____________________________________________________
Other: __________________________________________________________________
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Items to Destroy
Please destroy the following documents upon my death:
Item: ___________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Location: ________________________________________________________________
Item: ___________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Location: ________________________________________________________________
Item: ___________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Location: ________________________________________________________________
Item: ___________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Location: ________________________________________________________________
Item: ___________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Location: ________________________________________________________________
Item: ___________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Location: ________________________________________________________________
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Checklist for My Family: A Guide to My History, Financial Plans, and Final Wishes
© American Bar Association
letters to friends and Relatives
□ I do not have any letters for friends or relatives.
□ I have prepared letters for friends and relatives as follows:
Person:__________________________________________________________________
Address: ________________________________________________________________
________________________________________________________________________
Letter location: ___________________________________________________________
Person:__________________________________________________________________
Address: ________________________________________________________________
________________________________________________________________________
Letter location: ___________________________________________________________
Person:__________________________________________________________________
Address: ________________________________________________________________
________________________________________________________________________
Letter location: ___________________________________________________________
Person:__________________________________________________________________
Address: ________________________________________________________________
________________________________________________________________________
Letter location: ___________________________________________________________
Person:__________________________________________________________________
Address: ________________________________________________________________
________________________________________________________________________
Letter location: ___________________________________________________________
Person:__________________________________________________________________
Address: ________________________________________________________________
________________________________________________________________________
Letter location: ___________________________________________________________
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Memorial service
□ I do not want a memorial service.
□ I want a memorial service.
I wish the service to be for:
□ Friends and relatives
□ Private
□ Other: _________________________________
□ I wish to have the following at my memorial service:
House of worship:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Religious leader/Officiant/Clergy:
________________________________________________________________________
________________________________________________________________________
Speakers/Readers:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Ushers/Pallbearers:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Checklist for My Family: A Guide to My History, Financial Plans, and Final Wishes
© American Bar Association
Favorite scripture, psalms, poems, readings:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Special hymns, music, musicians, soloists:
________________________________________________________________________
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obituary
□ I have not written my own obituary.
□ I have written my own obituary.
My obituary is located: _____________________________________________________
I would like my obituary to appear in the following newspapers:
Newspaper name: ________________________________ _________________________
Newspaper website: ________________________________ _______________________
I would like my obituary posted online at: ______________________________________
I would like the following information to appear in my obituary:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Checklist for My Family: A Guide to My History, Financial Plans, and Final Wishes
© American Bar Association
People to Contact
Please inform the following people of my death:
Name: __________________________________________________________________
Relationship: _____________________________________________________________
Phone: ______________________________ Email: ______________________________
Address: ________________________________________________________________
________________________________________________________________________
Name: __________________________________________________________________
Relationship: _____________________________________________________________
Phone: ______________________________ Email: ______________________________
Address: ________________________________________________________________
________________________________________________________________________
Name: __________________________________________________________________
Relationship: _____________________________________________________________
Phone: ______________________________ Email: ______________________________
Address: ________________________________________________________________
________________________________________________________________________
Name: __________________________________________________________________
Relationship: _____________________________________________________________
Phone: ______________________________ Email: ______________________________
Address: ________________________________________________________________
________________________________________________________________________
Name: __________________________________________________________________
Relationship: _____________________________________________________________
Phone: ______________________________ Email: ______________________________
Address: ________________________________________________________________
________________________________________________________________________
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Pet Care
□ I do not have any pets.
□ I have not made arrangements for the care of my pets.
□ I have made arrangements for the care of my pets.
□ I have not made financial arrangements for the care of my pets.
□ I have made financial arrangements for the care of my pets.
I have made the following arrangements for the care of my pets:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I have made the following financial arrangements for the care of my pets:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Checklist for My Family: A Guide to My History, Financial Plans, and Final Wishes
© American Bar Association
Veterans Burial Benefits
□ I did not serve in the U.S. military.
□ I served in the U.S. military.
□ I or other family members may be eligible for veterans benefits.
□ I have a copy of my DD-214.
□ I want a burial flag for my casket.
□ I want burial in a national cemetery.
□ I want a veteran’s headstone.
□ I want military honors at the burial.
Name I served under while in the military:
________________________________________________________________________
First Middle Last
My DD-213 is located: _____________________________________________________
I entered active service on: _________________________________________________
I was separated from active service on: ________________________________________
Branch: _________________________________________________________________
Grade or rank: ___________________________________________________________
National Guard: __________________________________________________________
Reserves: _______________________________________________________________
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Whole body Donation
□ I do not wish to donate my body for medical science.
□ I have not made prearrangements with any medical school or research organization.
□ I have made the following prearrangements with the following medical school or research organization:
Medical school: ___________________________________________________________
Address: ________________________________________________________________
________________________________________________________________________
Phone: __________________________________________________________________
Contact person: ___________________________________________________________
Research organization: _____________________________________________________
Address: ________________________________________________________________
________________________________________________________________________
Phone: __________________________________________________________________
Contact person: ___________________________________________________________
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Checklist for My Family: A Guide to My History, Financial Plans, and Final Wishes
© American Bar Association
Medical and final Wishes: other
The following miscellaneous information about my final wishes may be of interest:
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