"IN REMEMBRANCE" DATA ENTRY

I understand that I am giving the KNIGHTS of COLUMBUS WILLIAMSPORT COUNCIL 366 and THE FATHER RECHSTEINER ASSEMBLY permission to post the information, presented on the form below, on the Internet. I have the LEGAL RIGHT to give this permission and do so freely. The COUNCIL and ASSEMBLY will not be held liable for any misrepresentation.

I want to:
ADD A NAME TO THE TRIBUTE.
UPDATE INFORMATION WITHIN THE TRIBUTE.
DELETE A NAME FROM THE TRIBUTE.

Full Name of Deceased Member:(First, MI, Last)

DATE OF BIRTH: MM/DD/YEAR ��DATE OF DEATH:MM/DD/YEAR

THIS MEMBER HELD THE FOLLOWING DEGREES:
FIRST DEGREE.SECOND DEGREE. THIRD DEGREE.FOURTH DEGREE. NOT SURE.

THIS MEMBER HELD THE FOLLOWING OFFICES:

WAS THIS MEMBER A VETERAN?
YES, THIS MEMBER WAS A VETERAN OF THE U.S. ARMED FORCES.
NO THIS MEMBER WAS NOT A VETERAN OF THE U.S. ARMED FORCES.

The following information must be provided. We will contact you to verify the authenticity of this request.

NAME OF PERSON SUBMITTING REQUEST:

RELATIONSHIP TO DECEASED MEMBER:
YOUR E-MAIL ADDRESS:

YOUR PHONE NUMBER:

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