Final Wishes Checklist

Use this handy guide to help have the conversation about how to honor the best of your life.

Or download a PDF of this guide here.

 

Quality Of Life:

If I were unable to maintain my quality of life, my loved ones will need to make arrangements for me to get the care that I need, either through living with a relative, a visiting nurse or nursing home, or an assisted living facility.

The circled statements describe scenarios, in which I feel that it is necessary for my family to take steps for me to receive assistance:

  • No longer being able to recognize family and friends
  • No longer being able to communicate with them and feel that I am being understood
  • No longer being able to think clearly
  • Feeling constant pain or discomfort
  • Frequently experiencing symptoms such as nausea, diarrhea, shortness of breath
  • No long being able to eat or drink
  • No longer being able to control my bladder and bowels
  • No longer being able to safely live in my own home

If assistance is required, are there any specific nursing homes, assisted living facilities,  or relative’s homes that you would like you family to take you to (if possible)?_______________________________


Prognosis:

If I were very ill and given little chance that I would live much longer, it is important to me that I be able to (circle the statement that applies):

  • Continue with all possible treatments in the hope that a miracle might happen to restore my heath
  • Be allowed to die with dignity and given medications to alleviate any pain that I may be experiencing

If I were in a coma and there was little hope of me regaining consciousness, I would like to (circle the statement that applies):

  • Be kept alive indefinitely in the hope that medical advancements would restore my health
  • Be kept alive for a set amount of time before discontinuing treatment. That amount of time is: ______________________________
  • Have all treatment discontinued, no new treatment started


Organ Donation:

I am currently an organ donor  YES  NO 

Upon my death, I would like to help save and heal the lives of others by donating my organs, eyes and tissue     YES     NO

I am not a registered organ, eye & tissue donor, but would like to save and heal lives through organ, eye and tissue donation  YES    NO

  • An individual can register their wishes at any time by joining the Ohio Donor Registry at www.lifebanc.org.

I am not a registered organ, eye & tissue donor, but understand that my family can make the decision upon my death     YES    NO

*If organ donation is declined due to religion, it is important to check with your religious/spiritual leader about the stance on donation. Most religions encourage organ donation and do not frown on it.

 

Cemetery:

I would like my remains to be:     Buried      Cremated

I would like a graveside prayer service     YES     NO

It is my desire to be buried with other members of my family    YES      NO

I have chosen which cemetery I would like to buried in   YES      NO

If yes, list cemetery:_____________________________________________________________________

If No:

Many non-religious people are buried in religious cemeteries, in order to rest alongside loved ones, I would consider being buried in a religious cemetery:   YES   NO

 

  • Criteria that I would like used by my family to select a final resting place would be:____________________________________________________________________

 

I prefer above ground burials     YES       NO

I visit the cemetery because it is comforting to be close to a loved one    YES    NO 

I have thought about making burial arrangements so my family is not burdened    YES     NO

 

Funeral/Burial Services:

The type of casket that I would like my family to select is  WOOD   METAL   OTHER:_______________

I would like to have an outer burial container/vault (this may prevent grave from sinking and is only required in some cemeteries):     YES     NO

If I choose to be cremated, I would still like to have a memorial service, giving my friends and family a chance to grieve in the company of loved ones   YES      NO  

Regarding my family gathering to say goodbye, I would like the mood to be (circle those that apply) :  Casual   Formal    Religious   Fun    Happy    Mournful

The music that I would like my family to enjoy is: ____________________________________________

The type of food that I would like my family to eat is:_________________________________________

I would like to be buried with these items:__________________________________________________

I would like to be wearing:_______________________________________________________________

I would also like to have ________________________________________________________to make my memorial service unique and personalized.

 

Memorial/Headstone:

There are many factors to consider, upon selecting a monument, I have rated the order of importance of the following factors:

____ Memorial being able to meet the requirements of the specific cemetery that I have chosen (in other words, the type of memorial that I have selected, is more important to me than the cemetery that I chose)

____ Cost, it is important to me that my family chooses a piece that uses the least expensive stonework/design

____ Cost, it is important to me that I be honored in the afterlife, by utilizing the best quality materials and design work

____Photo or vases included on the headstone

____ Religious markings or quotes

____The size of the headstone is important to me

____ Intricate design work of the headstone is important to me

____ I would prefer a bronze headstone

____ I would prefer stone headstone

I have already selected a company that I would like to design my memorial:    YES    NO

If Yes, please use:___________________________________________________________

 

 

I realize that this is not a legal document, but a tool to help clarify my wishes (please sign)__________________________________________________________________.

 

In the event that I have passed, the next time that my family views this document, I would like to say, as a final note:

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