var expressions = {};
window.expressions = expressions;
expressions.pairs=[];

expressions.send = function(form){
	if(typeof expressions.validate != null) if(r=expressions.validate()) { alert(r); return false; }
	for(var t=0; typeof form.elements[t] != 'undefined'; t++)
		if(form.elements[t].name.length){
			if(form.elements[t].type == 'checkbox' || form.elements[t].type == 'radio'){			
				if(form.elements[t].checked)
					expressions.pairs.push( form.elements[t].name + '=' + (form.elements[t].type == 'radio' ? escape(form.elements[t].value) : 1) );
			}else expressions.pairs.push(form.elements[t].name + '=' + escape(form.elements[t].value));
		}

	document.getElementById('resp').innerHTML = "<iframe allowtransparency='true' frameborder='0' style='border:0px;height:150px;width:300px' src='http://forms.expressionstributes.com/process.php?"+expressions.pairs.join('&')+"'></iframe>";
	form.style.display='none';
};
expressions.validate = function(){
	if(!document.getElementById('_name').value) return "You must enter your name.";
	return false;
};
function done(){
	if(expressions.validate()){
		alert(expressions.validate());
		return;
	}
	
	document.getElementById('_description').value='New preneed request from '+(document.getElementById('_name').value);
	
	if(expressions && document.getElementById('expressionsForm')){
		expressions.send(document.getElementById('expressionsForm'));
	}

	return false;
}
document.write("<form method='post' id='expressionsForm'>");
document.write('<table width="448" border="0" style="text-align: left; font-family: arial">');
document.write('<tr valign="bottom">');
document.write('<td style="padding: 10px 0" colspan="4" align="center">');
document.write('<strong>Personal Information</strong>');
document.write('</td>');
document.write('</tr>');
document.write('<tr valign="bottom">');
document.write('<td colspan="2">Name:</td>');
document.write('<td colspan="2" align="right"><input name="name" type="text" id="_name" size="30"></td>');
document.write('</tr>');
document.write('<tr valign="bottom">');
document.write('<td colspan="2">Marital Status:</td>');
document.write('<td colspan="2" align="right">');
document.write('<select name="marital_status" size="1">');
document.write('<option>Single</option>');
document.write('<option>Married</option>');
document.write('<option>Separated</option>');
document.write('<option>Divorced</option>');
document.write('<option>Widow</option>');
document.write('<option>Widower</option>');
document.write('</select>');
document.write('</td>');
document.write('</tr>');
document.write('<tr valign="bottom">');
document.write('<td width="120">Birth Date:</td>');
document.write('<td width="104" align="left"><input name="date_of_birth" type="text" id="date_of_birth" size="11"></td>');
document.write('<td width="120" class="border">&nbsp;&nbsp;&nbsp;<span class="fontmatch">Birth Place:</span></td>');
document.write('<td width="104" align="right"><input name="place_of_birth" type="text" id="place_of_birth" size="11"></td>');
document.write('</tr>');
document.write('<tr valign="bottom">');
document.write('<td colspan="2">Current Address: </td>');
document.write('<td colspan="2" align="right"><input name="address" type="text" id="address" size="30"></td></tr>');
document.write('');
document.write('<tr valign="bottom">');
document.write('');
document.write('<td width="120">City: </td>');
document.write('<td width="104" align="left"><input type="text" size="11" name="city"></td>');
document.write('<td width="120" class="border">&nbsp;&nbsp;&nbsp;<span class="fontmatch">State: </span>');
document.write('<td width="104" align="right"><input type="text" size="11" name="state"></td></tr>');
document.write('');
document.write('<tr valign="bottom">');
document.write('<td width="120">Zip: </td>');
document.write('<td width="104" align="left"><input type="text" size="11" name="zip"></td>');
document.write('<td width="120" class="border">&nbsp;&nbsp;&nbsp;<span class="fontmatch">County: </span></td>');
document.write('<td width="104" align="right"><input type="text" size="11" name="county"></td>');
document.write('</tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Phone: </td>');
document.write('');
document.write('<td colspan="2" align="right"><input type="text" size="30" name="phone"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">E-mail: </td>');
document.write('<td colspan="2" align="right"><input type="text" size="30" name="email"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Spouse\'s Name: </td>');
document.write('<td colspan="2" align="right"><input type="text" size="30" name="spouse_name"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Spouse\'s Maiden Name: </td>');
document.write('<td colspan="2" align="right"><input type="text" size="30" name="spouse_maiden_name"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Phone: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="person_in_charge_phone"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td style="padding: 10px 0" colspan="4" align="center"><hr><strong>Work/Education History</strong></td></tr>');
document.write('');
document.write('<tr valign="bottom">');
document.write('<td width="120">Education (0-12): </td>');
document.write('');
document.write('<td width="104" align="left" ><input type="text" size="11" name="education_0_to_12"></td>');
document.write('<td width="120" class="border">&nbsp;&nbsp;&nbsp;<span class="fontmatch">College 1-5+: </span></td>');
document.write('<td width="104" align="right" ><input type="text" size="11" name="college"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Occupation: </td>');
document.write('<td colspan="2" align="right"><input type="text" size="30" name="occupation"></td></tr>');
document.write('');
document.write('<tr valign="bottom">');
document.write('<td width="120">Business: </td>');
document.write('<td width="104" align="left"><input type="text" size="11" name="business"></td>');
document.write('<td width="120" class="border">&nbsp;&nbsp;&nbsp;<span class="fontmatch">Company: </span></td>');
document.write('<td width="104" align="right"><input type="text" size="11" name="company"></td>');
document.write('</tr>');
document.write('');
document.write('');
document.write('<tr valign="bottom"><td style="padding: 10px 0" colspan="4" align="center"><hr><strong>Military Record</strong></td></tr>');
document.write('<tr valign="bottom"><td colspan="2">Branch of Service: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="military_branch"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Serial Number: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="serial_number"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td width="120">Date Enlisted: </td>');
document.write('<td width="104" align="left"><input type="text" size="11" name="date_enlisted"></td>');
document.write('<td width="120" class="border">&nbsp;&nbsp;&nbsp;<span class="fontmatch">Date Discharged: </span></td>');
document.write('');
document.write('<td width="104" align="right"><input type="text" size="11" name="discharge_date"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Rank At Discharge: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="discharged_rank"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Discharge On File At: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="discharge_file"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Copy of Discharge Papers: </td>');
document.write('<td colspan="2" align="right" ><input type="checkbox" name="copy_of_discharge_papers">Yes <input type="checkbox" name="copyofdischargepapersno">No</td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Name Of Wars: </td>');
document.write('');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="name_of_wars"></td></tr>');
document.write('');
document.write('');
document.write('<tr valign="bottom"><td style="padding: 10px 0" colspan="4" align="center"><hr><strong>Funeral Service Request</strong></td></tr>');
document.write('<tr valign="bottom"><td colspan="2">Place Of Service:</td>');
document.write('<td colspan="2" align="right" ><select name="place_of_service" size="1">');
document.write('<option>Funeral Home</option>');
document.write('<option>Church</option>');
document.write('<option>Cemetery</option>');
document.write('</select></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Funeral Home: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="funeral_home"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Address: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="funeral_home_address"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Phone: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="funeral_home_phone"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Place of Visitation: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="place_of_visitation"></td></tr>');
document.write('');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Religious Denomination: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="denomination"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Place Of Worship: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="place_of_worship"></td></tr>');
document.write('');
document.write('');
document.write('<tr valign="bottom"><td style="padding: 10px 0" colspan="4" align="center"><hr><strong>Newspaper Information (Please list family members)</strong></td></tr>');
document.write('<tr valign="bottom"><td colspan="2" valign="top">Children: </td>');
document.write('<td colspan="2" align="right" ><textarea name="children" rows="2" cols="23"></textarea></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2" valign="top">Brothers/Sisters: </td>');
document.write('');
document.write('<td colspan="2" align="right" ><textarea name="siblings" rows="2" cols="23"></textarea></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Number of Grandchildren: </td>');
document.write('<td colspan="2" align="right" ><input name="number_of_grand_children" type="text" size="30"></td></tr>');
document.write('');
document.write('<tr valign="bottom">');
document.write('<td colspan="2" valign="top">Other significant relatives: </td>');
document.write('<td colspan="2" align="right" ><textarea name="additional_relatives" rows="2" cols="23"></textarea></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td style="padding: 10px 0" colspan="4" align="center"><hr><strong>Special Instructions</strong></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2" valign="top">Lodges and Organizations: </td>');
document.write('<td colspan="2" align="right" ><ol type="1">');
document.write('<li><input type="text" size="20" name="casket_bearer_1"></li>');
document.write('<li><input type="text" size="20" name="casket_bearer_2"></li>');
document.write('<li><input type="text" size="20" name="casket_bearer_3"></li>');
document.write('<li><input type="text" size="20" name="casket_bearer_4"></li>');
document.write('<li><input type="text" size="20" name="casket_bearer_5"></li>');
document.write('<li><input type="text" size="20" name="casket_bearer_6"></li>');
document.write('</ol></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Jewelry: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="jewelery"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Glasses: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="glasses"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Lodge / Union: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="lodge_union"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Clothing Preference: </td>');
document.write('<td colspan="2" align="right" ><input type="checkbox" name="clothing_preference" value="my own">My own <input type="checkbox" name="clothingpreferenceother" value="other">Other</td></tr>');
document.write('<tr valign="bottom"><td style="padding: 10px 0" colspan="4" align="center"><hr><strong>Disposition Request</strong></td></tr>');
document.write('<tr valign="bottom"><td colspan="2">I  Prefer: </td>');
document.write('<td colspan="2" align="right" ><select name="disposition_request" size="1">');
document.write('<option selected>Earth Burial</option>');
document.write('<option>Mausoleum</option>');
document.write('<option>Cremation</option>');
document.write('</select></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Cemetery: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="cemetery"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Address: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="cemetery_address"></td></tr>');
document.write('<tr valign="bottom"><td colspan="2">Phone: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="cemetery_phone"></td></tr>');
document.write('');
document.write('<tr valign="bottom"><td colspan="2">Section: </td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="cemetery_section"></td></tr>');
document.write('<tr valign="bottom">');
document.write('<td colspan="2">Last will and testament exists: </td>');
document.write('<td colspan="2" align="right" ><input type="checkbox" name="last_will">Yes <input type="checkbox" name="last_will">No</td></tr>');
document.write('<tr valign="bottom"><td colspan="2">Location:</td>');
document.write('<td colspan="2" align="right" ><input type="text" size="30" name="will_location"></td>');
document.write('<tr valign="bottom">');
document.write('<td colspan="4"><hr></td>');
document.write('</tr>');
document.write('<tr valign="bottom"><td colspan="2" valign="top"><strong>Other Instructions</strong>');
document.write('</td>');
document.write('<td colspan="2" align="right" ><textarea name="other_instructions" rows="2" cols="23"></textarea></td></tr>');
document.write('<tr valign="bottom"><td colspan="2" valign="top"><strong>Memorials/Donations To Charity</strong></td>');
document.write('<td colspan="2" align="right" ><textarea name="memorial_donations" rows="2" cols="23"></textarea></td></tr>');
document.write('<tr valign="bottom"><td style="padding: 15px 0" colspan="4"><strong>Please select all that apply:</strong> <br> <br>');
document.write('<input type="checkbox" name="send_info" value="send_info">Send information about pre-arrangement<br>');
document.write('<input type="checkbox" name="set_appointment" value="set_appointment">Contact me to set an appointment<br>');
document.write('<input type="checkbox" name="keep_info_on_file" value="keep_info_on_file">Please keep my information on file</td></tr>');
document.write('<input type="hidden" id="_description" name="description" value="">');
document.write('<tr valign="bottom"><td height="50" valign="top" align="center" colspan="4">');
document.write('<button onclick="return done()">Submit</button>');
document.write('</td></tr>');
document.write('</table>');
document.write("<input type='hidden' name='userid' value='321'>");document.write("<input type='hidden' name='locationid' value=''>");document.write("<input type='hidden' name='tag' value=''>");document.write("<input type='hidden' name='formType' value='1'>");
document.write("</form>");
document.write("<div id='resp'></div>");