Member Death Notification
American Gold Star Mothers, Inc.
For Chapters/Departments to notify the National Chaplain upon the death of an AGSM Member or Associate Member.
Notice is for:
AGSM Mother
Associate Member
Chapter Name:
Department:
Deceased Mother Name:
First Name
Last Name
Date of Death:
-
Month
-
Day
Year
Date
Place of Death:
Associate Member's Name
First Name
Last Name
Associate Member was:
Please Select
Dad
Sibling
Other(Complete box below)
If Other was marked above, please specify:
Obituary/Death notice found in what publication:
Newspaper
Website
Other
Publication Site:
Name of Publication or Website Address / City/State (if applicable)
Next of Kin Name:
First Name
Last Name
Next of Kin Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
*Memorial Acknowledgements will be mailed to the name/address above, unless otherwise specified.
Next of Kin Contact Information: Email
example@example.com
Next of Kin Contact Information: Phone Number
Please enter a valid phone number.
Person Submitting Information
First Name
Last Name
Person Submitting Information: Email
example@example.com
Person Submitting Information: Phone Number
Please enter a valid phone number.
Chapter/Department Chaplain Name:
First Name
Last Name
Chapter/Department Chaplain: Phone Number
Please enter a valid phone number.
Memorial Acknowledgements to Family Requested:
Yes
No
Notes:
Thank you for your thoughtfulness in notifying us and gathering as much information as possible.
If a memorial donation is sent to Headquarters, it will be listed in the next issue of “The Gold Star Mother” newsletter.
Form #NC01D (Rev. 02.01.21)
Submit
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