On-line Obituary Form

Obituary Form

* Name of deceased, including nickname:

* Age:

* Date of Death:

* Date of Birth:

* Place of Birth: (home / hospital name / other)

* City of Residence:

Cause of Death (optional):

Parents' names, mother's maiden name in parentheses: (Example: John and Mary (smith) Jones)

Military Service:

Career/Work Experience:

Hobbies and Interests:

Affiliations and Memberships:

Civic Honors/Awards:

Married: HeShe

Married to

On:

In:

Married: HeShe

Married to

On:

In:

Life/Domestic Partner: (synonymous with spouse)

Length of relationship:

Survivors

Spouse: (life/domestic partner)

Residence: (city & State)

If not: date of death

Parents (if living):

Grandparents (if living):

Children & Spouse (indicate if son or daughter):

Residence (city & state):

Siblings (indicate if brother or sister):

Residence (city & state):

Number of Grandchildren:

Number of Great Grandchildren:

Number of Great Great Grandchildren:

Preceded in death by (limited to spouses/children/grandchildren:

Services

Check here if no Service is planned

Time:

Date:

Location:

Visitation:

Time:

Date:

Location:

Burial, entombment, inurnment (indicate which):

Date:

Location:

Memorial contributions to:

Family Contact:

Phone:

Photo provided by family: YesNo

Sent to Newspaper via e-mail/upload: YesNo

Date to Run:

If Other, please specify

Newspaper charges vary, please ask a funeral director for detail.

IMPORTANT:

Before signing please verify that all information on this form is correct.

The undersigned hereby certifies that they are the person with the right to control final disposition of the above-named decedent, or otherwise have the legal authority to direct the arrangements of the decedent, and hereby authorize Smith Lund Mills to submit this obituary to specified newspapers and post the decedent's obituary on Smith Lund Mills' website and/or other website on the internet that list obituary and death notices. The undersigned takes responsibility for the accuracy of the information submitted and further acknowledges that once submitted and printed this obituary/death notice cannot be changed and will become part of the public domain. The undersigned authorizes the release of this information to the public and hereby release Smith Lund Mills from all liability that may arise from the printing or posting of this obituary/death notice and agrees to be financially liable for any expenses incurred for such requests.

* Email:

* Signed:

* Date:

Get in Touch

Smith Lund Mills Funeral Chapel & Crematorium

123 S 7th St.

Cottage Grove, OR 97424

Phone: (541) 942-0185