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:  
     
Is This a Member of a Lodge or Chapter?  
     
Select Highest Degree Held if any:  
     
NAME of Lodge or Chapter  
     
NUMBER of Lodge or Chapter  
     

Please Provide Details of Distress Report:
 
 

MEMBERS SHOULD SEND CARDS TO:
NOTICE: REPORT WILL NOT BE POSTED WITHOUT COMPLETE CARD INFORMATION!
 
Name:  
Addesss:  
Address:  
City:  
State:  
ZIP:  
 

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 DEATH
     
Date of Death:  
     
 
FUNERAL HOME INFORMATION:
     
Name:  
Address:  
City  
State  
Zip:  
Phone:  
     
 
VISITATION
     
Date:  
Hours:  
     
 
MOOSE TRIBUTE SERVICE
     
Date:  
Time:  
     
 
FUNERAL
     
Date:  
Time:  
     
     

     
PLEASE PROVIDE YOUR CONTACT INFORMATION
NOTE: NOTICE WILL NOT BE POSTED WITHOUT YOUR NAME AND A VALID EMAIL ADDRESS
Your Report will be posted after review within 24 hours
     
My Name Is:  
My E-Mail Address Is:  
     
To Prevent Spam, please correctly enter the
human readable text in the box
security code
   
     

 
 
 
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IMPORTANT NOTICE: The Loyal Order of Moose is a private organization. All activities and events referred to on this Web site and in the Moose newsletters published herein are available to members in good standing and their qualified guests only. This Web site is for informational purposes with proprietary information intended for members only. General information is available to the public at large, but should not be construed to be a solicitation for membership. This Web site is an initiative of the Virginia Moose Association, and is not sanctioned by the Loyal Order of Moose, Moose International or any subsidiary thereof. All logos, trademarks and servicemarks pertaining to the Loyal Order of Moose and/or its programs or degrees are copyrighted © by Moose International, Inc., Mooseheart, Illinois.
 

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