Name: Deceased Rotarian
Start: 2020-10-12T08:00:00-04:00
End: 2021-06-30T17:00:00-04:00

Please provide the information requested so that we can inform the membership of the passing of one of our own.

Contact Information
You are the point person for information about the deceased.
Name of person completing this form*
First Last
Email*
Enter Email Confirm Email
Preferred Phone Number*
In case we need more informaiton
Deceased Rotarian information
Rotarian or Honorary*
Was the Deceased an active Rotarian or Honorary Member at the time of passing.
- Rotarian
- Honorary
Name of Deceased*
Prefix First Last Suffix
Rotary Club of Deceased Rotarian*
Date of Passing*
Date Format: MM slash DD slash YYYY
Name of spouse or family member*
Name of Spouse or Family Member who can receive notes, cards, flowers, etc.
First Last
Address of spouse or family member*
Street Address Address Line 2 City State ZIP Code
Link to the Funeral Home - must have*
Please provide the link to the Funeral Home

Deceased Rotarian

Contact Information