The Emporia Gazette

May 28, 2012

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Submit an obituary

OBITUARY FORM

Obituaries are printed at no charge in The Emporia Gazette. Before you fill out this form, please contact the funeral home of the deceased. Most funeral homes will submit obituary information to us on your behalf. To include a photo with an obituary, please contact our Display Advertising office at 620-342-4803.

Deceased

Deceased name:

Address:

city:

Zip code:

Age:

Death Information
Date of death:

Place of death:

Cause of death:

Life Information
Date of birth:

Place of birth : (city, state)

Occupatioin:

Church membership: (city, state)

Occupatioin:

Other memberships:

Family Information:
Parents' names: (first, last)

Spouse: (first, last)

Date of marriage:

Place of marriage:

Survivors:

Deaths of others:

Funeral Information
Funeral Home: (include street, city, state)

Time of funeral:

Place of funeral:

Visitation: (time,place)

Ocfficiant:

Memorial:

Other information:

Form completed by:

Your Name:

Date:

Your telephone number:

Your email address:

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