Birthday Form

This form may be filled out by the pastor, church secretary, church clerk or communication leader. Please Verify spellings and dates.


First

Last
 
Illinois Conference
Indiana Conference
Lake Region Conference
Michigan Conference
Wisconsin Conference


Please fill in all blanks and VERIFY all information.

First

Last
 
Male
Female

is
was


First

Last
 

Centenarian's spouse is living.
Centenarian's spouse is deceased.
Centenarian is divorced.