Obituary Submission

Up to 300 words........$50.00

301 words or more...$100.00

(Prices include photo)

Name of deceased: *

Age: *

Residence: *

Death (date & place): *

Date of Birth: *

Place of Birth: *

Parents: *

Spouse (survives, yes or no?): *

Church Affiliation: *

Occupation: *

Organizations: *

Other Data:

Survivors (daughters, sons, sisters, brothers, others): *

Photograph to be included:

Your contact information:

Name: *

Address: *

City: *

State: *

Zip: *

Phone: *

Email: *