Report the death of a member

Deceased Member Information
Full Name of Deceased *

First Name Last Name
Royal Neighbors Certificate Number
Additional Certificates (if any):
Date of Birth

Month Day Year
Date of Death *

Month Day Year
Cause of Death

Natural Accidental Other
Location of Death

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Your Information
Full Name *

First Name Last Name
Phone Number

Area Code Phone Number
E-mail
Your Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Relationship
Funeral Home
Name of funeral home
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
Beneficiary Information
Please provide the following information for each Beneficiary: Full Name, Phone Number & Address
Additional Information
Please enter any additional comments
Should be Empty: