Sheffron Law Firm, P.A.

Hendersonville, NC

828-698-9889

___________________________________________________

Name

1. In case of Emergency I Request the Following Individuals be Contacted:

______________________________ _____________________

Name – Power of Attorney Telephone

______________________________ _____________________

Name – Healthcare Surrogate Telephone

______________________________ _____________________

Name – Executor of my Will Telephone

2. My Powers of Attorney, Healthcare Directives and Last Will can be found:

________________________________________________________________

3. My Physician is:

______________________________ _____________________

Name Telephone

4. My Dentist is:

______________________________ ______________________

Name Telephone

5. My Attorney is:

SCOTT H. SHEFFRON 828 698-9889

Name Telephone

6. My Financial Advisor is:

_____________________________ ______________________

Name Telephone

7. My Minister / Clergyman is:

______________________________ _____________________

Name Telephone

In order to assist my loved ones, I leave the following guidance.

1. I have made pre-need arrangements: _______ _______

Yes No

(If yes, paperwork should be attached)

2. I have not made pre-need arrangements but desire the following:

a. ________Burial or ______ Cremation

Location and Instructions:

___________________________________________________

b. I desire a funeral to be held: ______ ______

Yes No

Location and Instructions:

___________________________________________________

3. Miscellaneous Directives

___________________________________________________

Sheffron Law Firm, P.A.

Hendersonville, NC

828-698-9889