Bereavement Ministry/Funeral Request
Contact name
First Name
Last Name
Contact phone
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Area Code
Phone Number
Contact email
Relationship to the deceased
Name of deceased
First Name
Last Name
Date of transition
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Month
-
Day
Year
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Is the deceased a member of COZ?
Yes
No
Proposed date #1
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Month
-
Day
Year
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Proposed
1
2
3
4
5
6
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8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Proposed date #2
-
Month
-
Day
Year
Date Picker Icon
Proposed
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Will your family require a repast?
Yes
No
Submit
Should be Empty: