Because Funeral Requests require immediate response,
please print
this form, complete and
call 1-215-988-1900 or fax it to 1-215-988-1951.
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| Name of Brother: | ___________________________________________ |
| Place of Residence: | ___________________________________________ |
| His Lodge: | ___________________________________________ |
| Location of Lodge: | ___________________________________________ |
| Date of Death: | ___________________________________________ |
| Initiated: | ___________________________________________ |
| Funeral Home: | ___________________________________________ |
| Address of Funeral Home: | ___________________________________________ |
| Date of Service: | ___________________________________________ |
| Name of Requester: | ___________________________________________ |
| Time & Date Request submitted: | ___________________________________________ |
| Address of Requester: | ___________________________________________ |
| Phone Number of Requester: | ___________________________________________ |
| Service Done By: | ___________________________________________ |
| Was the deceased in good standing in his lodge? |
| Remarks or Pertinent Facts. | ___________________________________________ |
| ___________________________________________ |
| ___________________________________________ |
| ___________________________________________ |
| ___________________________________________ |
