Date of this report  - mm/dd/yy             

Auxiliary Number            District Number          

Enter Name of person completing report  online   

Enter Chairman's name            

        street address                   

      city state and zip                 

      Phone                                     999-999-9999

    Email:                

    You must enter an email address where you can be reached.  If the chairman doesn't have an email address, enter the email

    of the person completing the report.

NAME of Deceased Sister      AUX#                 DISTRICT#   

DATE OF DEATH - mm/dd/yy              NAME OF CEMETERY   

NEXT OF KINRELATIONSHIP

  ADDRESS  (To Whom Memorial is to be mailed)

                 Street      

                   City        State           Zip 

FUNERAL HOME NAME & ADDRESS 

Membership #