john backoffCHANHASSEN PIONEER CEMETERY
Please take a moment to review your family member(s) information and verify its accuracy, mark
any changes or additions below. Thank you again for your time.
Name of Deceased:
Maiden Name:
Date of Birth: Date of Death:
Place of Birth: Place of Death:
Cause of Death: Age:
Father: Mother:
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Spouse's
Children:
Occupation:
ate of Marriage:
If you would like to include a paragraph about their life i.e. associations, career, church
membership, date of marriage, children, accomplishments, etc., we would be happy to include
this information in the book as well.
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Form Completed By:
Name' Date :
Address Phone:
If you have any questions please call Karen Engelhardt at 937-1900.
Return to: 690 Coulter Drive, P.O. Box 147, Chanhassen, Minnesota 55317
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