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Deceased Information
Name and Age of Deceased
Residence of Deceased
Place and Time of Death (Day, Date, Time)
Services (check all that apply)
Funeral
Graveside
Burial
Cremation
Funeral Date/Time
Funeral Location
Memorial Date/Time
Memorial Service Location
Who Officiated?
Organist
Soloist
Interment is Where:
Vigil Services/Rosary Services:
Officiated by Whom?
About the Deceased:
Date and Place of Birth
Father's Name
Father Living or Deceased?
Living
Deceased
Mother's Maiden Name:
Mother Living or Deceased?
Living
Deceased
Name of Spouse (include maiden name, if applicable)
Spouse Living or Deceased?
Living
Deceased
If Spouse is Deceased, Date of Death
When and Where Married?
Career Information: Give a BRIEF description of occupation, education, military or other special honors:
Other Survivors? Children's Names, Names of Spouses and Where They Live, if Applicable:
Brothers and Sisters (with spouses and where they live):
Number of Grandchildren
Number of Great-Grandchildren
Number of Great-Great-Grandchildren
Preceding in Death
Please list name and relationship to deceased
Pallbearers:
Memorials May Be Made To:
Name of Funeral Home in Charge of Services:
Name and Phone Number of Person Who May be Contacted in Case More Information is Needed:
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Council Grove Republican
P.O. Box 237,
302 W. Main,
Council Grove, KS 66846
(620) 767-5123
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