BEREAVEMENT NOTICE

BEREAVEMENT NOTICE
GENERAL CONTACT INFORMATION
Name of Deceased Person

First Name Last Name
Was Deceased a Member of SMBC?:

Yes No
If No, Springhill Member(s) Name(s):
Relationship to Deceased:
SMBC Member Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
FUNERAL INFORMATION
Funeral Home Name:
Funeral Home Address:
Funeral Home Phone Number:
Funeral Home FAX Number:
Date of Funeral, if known:

Month Day Year
Date
Time of Funeral

: Hour Minutes AM/PM Option
Location of Funeral:
Location of Funeral (address):
Name of Person Completing the Form

First Name Last Name
E-mail
Additional Information:
Should be Empty: