1005 Grand Ave • PO Box 65665 •

West Des Moines, IA 50265 • 515.223.1197

Death Report

This is for pastors (or lay leaders) to report a member's death

My position in the church

Pastor / Lay Leader

Clerk

Relative / Friend

Our Church information & Event Details

Church Where membership was held?

Iowa

Missouri

IA Church

MO Church

Your Name

First Name

Last Name

Your Email

The ACTUAL date of death is needed. Try funeral home/newspaper obits online or www.legacy.com, tributes.com, findagrave.com or other search sites.

I know the Date of Death

Yes

Approximate date

Date of Death

Approximate Date of Death

County of Residence at death

Funeral Home Name

Residence at death (where s/he lived)

City & State of Funeral Home

Interment/Burial/Inurnment (include city/state):

Link to (URL of) Online Obituary

File Upload

Choose File

Deceased Person's Information

Title

First (given) Name

Name s/he Goes by /Prefers - Optional

Middle name

Last name

Suffix

Gender

Male

Female

Marital Status

I know the Date of Birth

Yes

Approximate date

Date / Approximate Date of Birth

Where was s/he born?

Address

Address Line 1

Address Line 2

City

State

Zip Code

Church office held at death

Was s/he ever a Denominational (SDA) employee?

Yes

Unknow

Other Church office previously held

Where? & In what capacity?

Deceased Person's Information

Father's Name

Dad Survivor?

Yes

Unknown

Father's date of death

Mother's Name

Mom Survivor?

Yes

Unknown

Mother's date of death

First Spouse's Name

File a Auto Claim

Person Reporting Incident

First Name

Last Name

Phone

Basic Claim Information

Name of Church/school that sponsored event

Date of Accident

Time of accident (if known)

Location of accident

Address Line 1

Address Line 2

City

State

Zip Code

Description/Nature of Accident/Incident

Was the accident reported to the police?

Yes

Date reported

Report number

Name of investigating organization?

Were any citations issued?

Yes

Church-Insured Vehicle Information

Year

Make

Model

VIN number

Name of registered owner

Name of driver

Drivers date of birth

Drivers Email

Drivers Phone number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Reason for vehicle use at time of accident

Was the vehicle used with permission?

Yes

Was the driver injured?

Yes

Describe damage to vehicle

Address where the vehicle may be seen for an estimate

Address Line 1

Address Line 2

City

State

Zip Code

Were there any passengers in the church-insured vehicle?

Yes

How Many Passengers?

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Damaged Property and Other Vehicle Information

Type of damage

Describe damaged property

Describe damage to vehicle

Year

Make

Model

License plate number

Insurance company

Policy number

Name of driver

Drivers email address

Drivers phone number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the driver injured?

Yes

Witnesses

Was there any witnesses?

Yes

How Many?

Name of Witness

Witness's Email

Witness's Phone

Witness's Address

Address Line 1

Address Line 2

City

State

Zip Code

Name of Witness

Witness's Email

Witness's Phone

Witness's Address

Address Line 1

Address Line 2

City

State

Zip Code

I certify that the information I have provided is truthful to the best of my knowledge.

Church Attendance Form

Attendance Report

This Report Should be Completed Each Month Following the Final Sabbath.

Month/Year Being Reported

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URL

Link Text

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Membership Records

Baptism Report

POF Report

Re-Baptism/Reclaim Report

Death Notice

Report Missing or Removal Vote

Request Membership Transfer

Report Transfer Vote Date

Attendance Slips (Keep at Church)

Instructions for Attendance

Church Officers Report

National Servicemen's Org. Survey

Adventist Church Manual

Ethnicity Determination Guide

National Church/School Locator

Meet the Team

Rob Alfalah

Ahylin Aceves

Community

Find a Church

Find a School

Share a Story

Prayer Requests

Church Life

Background Checks

Forms and Reports

Calendar

Give Back

Online Giving

Planned Giving

Food Label Program

The ACTUAL date of death is needed. Try funeral home/newspaper obits online or www.legacy.com, tributes.com, findagrave.com or other search sites.

1st Sabbath

2nd Sabbath

3rd Sabbath

4th Sabbath

5th Sabbath

Membership Records

Meet the Team

Content

Rob Alfalah

Ahylin Aceves

Community

Find a Church

Find a School

Share a Story

Prayer Requests

Church Life

Background Checks

Forms and Reports

Calendar

Give Back

Online Giving

Planned Giving

Food Label Program

Death Report

Our Church information & Event Details

Your Name

The ACTUAL date of death is needed. Try funeral home/newspaper obits online or www.legacy.com, tributes.com, findagrave.com or other search sites.

Deceased Person's Information

Deceased Person's Information

File a Auto Claim

Person Reporting Incident

Basic Claim Information

Church-Insured Vehicle Information

Damaged Property and Other Vehicle Information

Witnesses

Attendance Report

Number of Sabbaths in the Month?

1st Sabbath

2nd Sabbath

3rd Sabbath

4th Sabbath

5th Sabbath