Instructions for Notifying Masonic Organizations of My Death
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 _____________________