Death Notification Form

Instructions for Notifying Masonic Organizations of My Death

TO MY SURVIVORS: Upon my death, please notify my Masonic Lodge and the

following Masonic Organizations.

(My Lodge can be contacted by calling the Grand Secretary’s office at the Grand Lodge

of Georgia, F. & A. M., (478) 742-1475. That office will provide you with the name

and telephone number of the current Lodge Secretary.)

Lodge Name: ____________________________________________ No: _____________

Lodge City : ____________________________________________ Lodge State: ______

Other Masonic organizations to which I may belong:

[ ] Scottish Rite, Valley of _________________________________________________

[ ] York Rite ___________________________________________________________________

[ ] Shrine, Temple _____________________________________________________________

[ ] Order of Eastern Star ______________________________________________________

[ ] Amaranth ___________________________________________________________________

[ ] Red Cross of Constantine ________________________________________________

[ ] Other _____________________________________________________________________

[ ] Other _____________________________________________________________________

[ ] Other _____________________________________________________________________

[ ] Other _____________________________________________________________________

I request the following:

[ ] Yes, I want Masonic Services or

[ ] No, I do not want Masonic Services

My Masonic apron may be found at ________________________________________________

_______________________________________________________________________________________

(Note: My apron should accompany my body to cremation or burial.)

My Name _______________________________________________________________________________

Address _______________________________________________________________________________

City ___________________________________________________ State ________ Zip ___________

(Signed)________________________________________________________ Date _____________________

(Note: Must be signed. Give a copy of this page to your Lodge Secretary. Use the back

of this page to write your family any personal and specific directions that you might

have such as the disposal of your Masonic paraphernalia.)

Created by the Georgia Fifth Masonic District Convention and approved by the Educational and

Historical Commission, 2016.