Member Death Notification

Member Death Notification

For Chapters/Departments to notify the National Chaplain upon the death of an AGSM Member or Associate Member.
Name of Person reporting the death*

First NameLast Name
Reporting Person Email*
example@example.com
Reporting Person Phone Number*
Please enter a valid phone number.
Deceased Member Chapter Name*
Deceased Member Department Name*
Notice is for*
Description of Other
Deceased Member's Name*

First NameLast Name
Date of Death*

MonthDayYear
Date
Place of Death
Obituary / Death Notice found in which publication

NewspaperWebsiteOther
Name of Newspaper, Website Address, or Other
City and State of Newspaper Publication
Next of Kin Name*

First NameLast Name
Next of Kin Relationship*
Next of Kin Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Next of Kin Phone Number
Please enter a valid phone number.
Next of Kin Email
example@example.com
*Memorial Acknowledgements will be mailed to the name/address above, unless otherwise specified.
Chapter / Department Chaplain Name

First NameLast Name
Chapter / Department Chaplain Email
example@example.com
Memorial Acknowledgements to Family Requested

YesNo
Additional Notes for National Chaplain
Thank you for your thoughtfulness in notifying us and gathering as much information as possible.

If you have any additional information or questions, please contact the National Chaplain at Chaplain@AmericanGoldStarMothers.org

If a memorial donation is sent to Headquarters, it will be listed in the next issue of “The Gold Star Mother” newsletter.
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