Funeral Requests
Because Funeral Requests require immediate response,
please print this form, complete and
call 1-215-988-1900 or fax it to 1-215-988-1951.
Name of Brother:___________________________________________
Place of Residence:___________________________________________
His Lodge:___________________________________________
Location of Lodge:___________________________________________
Date of Death:___________________________________________
Initiated:___________________________________________
Funeral Home:___________________________________________
Address of Funeral Home:___________________________________________
Date of Service:___________________________________________
Name of Requester:___________________________________________
Time & Date Request submitted:___________________________________________
Address of Requester:___________________________________________
Phone Number of Requester:___________________________________________
Service Done By:___________________________________________
Was the deceased in good standing in his lodge?
Remarks or Pertinent Facts. ___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
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