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Information Submission Form
Everything on this form is optional. You may choose to fill in as much or as little as you would like. The only required bits of information are the name and email address of the person completing it.

Information of Person Completing the form:

Your name:   Email Address:

Mailing Addres: Apt #:

City: State: Zip:

Phone Number:


Future Deceased's Information:

Basic Information

Legal name: Maiden name:

Title: Name for the Media

Physical Address: Apt#:

City: State: Zip:   Inside City Limits?Yes No


Mailing Address: Apt#:
(if different from physical)

City: State: Zip:


Death Certificate Information

Date of Birth:   Month: Day: Year:    City or County State

Years of Education:   Usual Occupation: Type of Business:

Marital Status:     Race:

Obituary Information

Spouse:    Maiden:

Father:    Living   Deceased

Mother:    Maiden: Living   Deceased

Survivors (include city/state of residence):

Preceded in death by:

Number of:   Grandchildren:    Great-Grandchildren:    Great-Great-Grandchildren:

Church Membership:

Background Information :


©2007 Sossoman Funeral Home, All Rights Reserved
Created by Brandon Koontz