Sickness & Distress Report Sickness & Distress Report Please complete the form with the specific information requested, do not attempt to add information not asked for in the form, for example in visitation, put ONLY date and hours, do not add in any details NOTICE: It is the Reporters Responsibility to be sure that the person named (or family in case of death) is in agreement to have the information posted. Sick or distressed member information Name of Member Sick or Deceased: First Last Is This a Member of a Lodge or Chapter? — Select — Chapter Lodge NAME of Lodge or Chapter NUMBER of Lodge or Chapter Please Provide Details of Distress Report: Members Should Send Card To: Address IF DEATH, PLEASE PROVIDE FUNERAL DETAILS NOTICE: A Death Notice WILL NOT BE POSTED without complete information (Funeral Home, Visitation, Funeral, etc). If you do not have this information, do not submit report until you have the information Date of Passing Date and Time of Visitation Date and Time of Funeral FUNERAL HOME INFORMATION: Your Contact Information NOTE: NOTICE WILL NOT BE POSTED WITHOUT YOUR NAME AND A VALID EMAIL ADDRESS Your Name First Last Your Phone and Address Email Address
