Burial/Memorial Service Form

Date
Name of Deceased:*
First Middle Last
Date of Death
Employee
Relationship to Employee
Date of Funeral
Time of Funeral

: Hours

Minutes

AM/PM
Name of Mortuary
Address of Mortuary
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Telephone Number:
Fax Number:
Name of Responsible Party
Address of Responsible Party
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Telephone Number of Responsible Party:
Email of Responsible Party
Cell of Responsible Party:
Relationship to Deceased
Funeral Director's Signature
Please print, sign and have the Funeral Director's signature on the form before emailing it back to Allfaiths@pvamu.edu
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