Reports of Sickness or Distress

NOTICE: It is the responsibility of the reporter to be sure that the person named (or the family in case of death) is in agreement to have the information posted.

SICK or DISTRESSED MEMBER INFORMATION

Name of Member Sick or Deceased:

Is This a Member of the Lodge or Chapter?
LodgeChapter

Name of Lodge or Chapter:

Lodge or Chapter Number:

Please Provide Details of Distress:

MEMBERS SHOULD SEND CARD TO:

Address:

IF DEATH, PLEASE PROVIDE FUNERAL DETAILS

NOTICE: A Death Notice WILL NOT BE POSTER without complete information (Funeral Home, Visitation, funeral, etc). If you do not have this information, do not submit report until you have the information.

Date of Passing:

Date and Time of Visitation:

Date and Time of Funeral:

Funeral Home Information:

Interested in a "Breaking of the Circle" ceremony?
NoYes

YOUR CONTACT INFORMATION

NOTE: Notice will not be posted without your name and a valid email address.

Your Name:

Your Phone and Address:

Your Email Address: