Submitter's Name Submitter's Email Name and Phone Number of Person Who May be Contacted in Case More Information is Needed: Deceased Information Name and Age of Deceased Residence of Deceased Place and Time of Death (Day, Date, Time) Place and Time of Death (Day, Date, Time): Date Place and Time of Death (Day, Date, Time): Time Services (fill out all that apply) Funeral Date/Time Funeral Date/Time: Date Funeral Date/Time: Time Funeral Location Memorial Date/Time Memorial Date/Time: Date Memorial Date/Time: Time Memorial Service Location Who Officiated? Organist Soloist Interment is Where: Vigil Services/Rosary Services: Officiated by Whom? Pallbearers: About the Deceased: Date of Birth Place of birth Father's Name Father Living or Deceased? Mother's Maiden Name: Mother Living or Deceased? Name of Spouse (include maiden name, if applicable) Spouse Living or Deceased? If Spouse is Deceased, Date of Death When and Where Married? Career Information: Give a BRIEF description of occupation, education, military or other special honors: Other Survivors? Children's Names, Names of Spouses and Where They Live, if Applicable: Brothers and Sisters (with spouses and where they live): Number of Grandchildren Number of Great-Grandchildren Number of Great-Great-Grandchildren Preceding in Death Memorials May Be Made To: Name of Funeral Home in Charge of Services: Photo One file only.20 MB limit.Allowed types: gif, jpg, jpeg, png. Leave this field blank
