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 _____________________