Death Notice

Name of person providing information

Your email address:

Relationship to deceased

Daytime phone

Full name of deceased

Age

City, State

Date of death (yyyy-mm-dd)

Date of birth (yyyy-mm-dd)

Parents names Survive YesNo

Date and place of marriage

Spouse’s maiden name, if applicable Survive YesNo

If yes, where?

If no, give date of death, if known

Other survivors, list by relationship/give town of residence

Names of any deceased children of the decendant

Biographical information for deceased

Service information, including place of burial and officiating clergy

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