Obituary Form

Deceased Information
Name of deceased:
Sex:	Female Male
Age:
Maiden name (if married):
Place of death (home/name of hospital/other):
Date of death:
Long/short illness:
Place of residence (specific community/town/city):
Dates of residence in the Buffalo or surrounding area:
Date deceased left the area (if applicable):
Birthplace (city/state):
Spouse:
Date of spouses death (if applicable):
Occupation:
Name of Firm:
Job Title:
Dates of employment:
Date of retirement (if applicable):
Education (0-12):
College 1-5+:
Branch of Service:
Serial Number:
Date Enlisted:
Rank At Discharge:
Date Discharged:
Discharge On File At:

Religious affiliations:

Clubs, organizations, memberships, hobbies:

Honors/awards:

Survivors
(The newspaper will only use names of the immediate family as listed below. The city or town and state of the survivors must be included) Daughters: Sons: Parents: Sisters: Brothers: Grandparents:
Number of grandchildren:
Great-grandchildren:

Funeral Service Information
Time of Service:
Street Address:
City
State
Church Information
Street Address:
City
State
Cemetery Information
Street Address:
City
State
Contact Information
Who can we contact regarding this obituary:
E-mail:
Phone Number: