Bereavement Notification Alert
Please complete the information below as detailed as possible. Our Bereavement Director will contact you within 24 hours after this form is submitted.
Full Name of Deceased
*
First Name
Last Name
Is the deceased a member of Union Baptist Church, Winston-Salem?
*
Yes
No
Full name of person reporting this death
*
First Name
Last Name
E-mail
*
example@example.com
Retype E-mail
*
example@example.com
Are you a member of Union Baptist Church?
*
Yes
No
The deceased is my:
Mother
Father
Mother-in-Law
Father-in-Law
Son
Daughter
Brother
Sister
Uncle
Aunt
Cousin
Nephew
Niece
Granddaughter
Grandson
Other
Address (location where the family is gathering)
Street Address
Apt #
City
State / Province
Postal / Zip Code
Family Contact Phone Number
Must be the number of the family contact on this form
Can we share your contact information with our leadership team?
Yes
No
Are there any additional family member names that you would like for us to add to our email correspondences? Please list their relationship to the deceased.
Please provide service details in the space below. Please include date, time and location of visitation and funeral service.
Name and address of the funeral home.
Any additional information we need to know? Please include in the box below
By signing below, you agree that the above information is accurate.
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