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

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Last Name

Given Name and Initial

Maiden Name

Marital Status*To help us make sure we don't omit needed information, please select one of the following options:

Never married

Married, divorced or widowed

Former married name(s) of female deceased

Age at Time of Death

Date of Birth

Place of Birth

Date of Death

Place of Death

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She

was a member of the

Church Name

Church Location

Surviving Family Members: Give each man's given name, initial, and family name as he is known, and give each woman's given name and initial, (maiden name), and married name. Separate the family members' names with commas. Do not list deceased family members.

These are the only family members we list. Aunts and uncles, nieces and nephews, and cousins are not listed. Space does not permit listing the city where each surviving family member lives.

Survivors Include:

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His Wife

Her Husband

Name if Living

First

Last

Surviving Spouse's Maiden Name (if applicable)

Son(s) if Living

Stepson(s) if Living

Daughter(s) if Living

Stepdaughter(s) if Living

Foster Child(ren) if Living

Father if Living

Mother if Living

Mother's Maiden Name if Living

Brother(s) if Living

Stepbrother(s) if Living

Half Brother(s) if Living

Sister(s) if Living

Stepsister(s) if Living

Half Sister(s) if Living

Number of Grandchildren if Living

Number of Step-Grandchildren if Living

Number Great-Grandchildren if Living

Number of Step-Great-Grandchildren if Living

Number of Great-Great-Grandchildren if Living

Number of Step-Great-Great-Grandchildren if Living

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Funeral services were conducted by

Graveside services were conducted by

Memorial services were conducted by

Officient(s)

Place of Burial or Cemetery

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Interment (if buried) was in

Inurnment (if cremated) was in

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Cemetery

Mausoleum

Private inurnment (if deceased's ashes were given to the family)

City or Township and State

NOTE: These records may be used by people who are doing genealogy research, so the information must be as complete and accurate as possible. Be particularly careful to include the women's full names, including the maiden name (if possible), so people can trace both sides of their family tree.

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