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This survey was created for your convenience. The purpose of this survey is to help you remember details about the loved one who has passed away. This survey can also be used by a person who is facing imminent death due to long-term disease and who wants to plan his/her own tribute. Please ignore the questions that you feel are irrelevant and add your own questions to make as complete a living memory of your loved one as possible. The final tribute that you will create could be used by future generations to know, remember and appreciate the diseased person and create fond memories. Please ask all relatives and friends from around the world to add comments at the end of your tribute page so the tribute can become a living memorial.


Name: First, Middle, Last, Jr, Sr, III

Date of birth, place of birth, date of death, place of death, died due to: Natural causes, old age, disease?

Brothers and sisters, what number child (only child, third kid, eldest, youngest)

Place of childhood: Spent childhood, what school, special memories?

Best friends


Jobs, career

Married when, to whom, at what age,

How many marriages, divorces, step children, ex-wives,

How many children, boys, girls,

Children’s education and careers

Role as a grand father/grandmother

Overall health, health issues

Grand children, boys, girls,

Cities lived

Places visited, in USA, in the World

Tragic incidents that took place in his/her life.

Happy incidents that took place in his/her life.

Successes in life, failures in life

Accomplishments in his/her view

Goals met. Dreams, plans,

Role of father, mother, brother, sister, husband, wife, son, daughter

Community role, (PTA member, elected post, voluntarily assumed roles)

Religious role,

Dedicated father/mother

How friends, neighbors viewed him/her,

Helped people, admired by people, remembered by people

Wrote books, received patents, awards

Wrote songs, poems, newspaper articles, magazine articles,

Languages spoke

Musical, artistic talent

Bravery incidents

Temperament, type of personality, usual mood

Loving, caring, giving, nurturing, happy, lucky, responsible, goal oriented, organized, adventurous, risk taker, god fearing, religious minded, funny, quiet, sweet

 Setbacks in life

Travels, pilgrimages, (land, sea, air)

Places visited

Property (type of property, own houses, classic car, motorcycle or airplane)

Hobbies, interests,

Favorite authors, poets, writers

Favorite music

Favorite sport teams

Favorite food, drinks,

Favorite church, charities, activities

Favorite places to visit, places to eat, places to relax and enjoy

Military service, achievements, medals, honors, heroic events, memorable events,

Favorite pet

How his/her living changed the people around him

His/her impact on life

What he/she left behind

What he/she taught us. What we learned from him/her