Deceased's InformationFirst NameMiddle NameLast NameDate of DeathMonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923AgeSexMaleFemaleName of Place of Death(home/hospital name/other)City & State of ResidenceShort/Long Term Illness(es)Date of BirthMonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923City/State/Country of BirthMarital StatusMarriedNever MarriedWidowedDivorcedMaiden Name (if wife)Full Name of Surviving Spouse (if applicable)Date of Death of Spouse (if applicable)MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923Occupation (most of life)EmployerJob TitleDate of EmploymentDate of RetirementEducationReligious AffiliationsClubs/Organizations/Memberships/HobbiesHonors/AwardsVeteran InformationBranch of ServiceDate EnlistedMonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923Date DischargedMonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923Rank at DischargeMilitary Serial NumberHonorable Discharge?YesNoIs Copy of Discharge Papers Available?YesNo(If no, please bring to us to copy.)Location Where Discharge Papers Are On FileSurvivorsNewspapers will only use names of the immediate family as listed below. The city or town and state of the survivors must be included - separate each piece of the individual's information with a comma and a space. Put each family member on his/her own line.DaughtersSonsParentsSistersBrothersGrandparentsNumber of GrandchildrenNumber of Great GrandchildrenFuneral Service InformationDate & Time of ServicePlace of ServiceStreet Address & City of ServiceChurch InformationName of ChurchAddress of ChurchCemetery InformationName of CemeteryAddress of CemeteryYour Contact InformationFirst NameLast NameRelationship to DeceasedPhoneEmail AddressOther Information & InstructionsSend Message
