Before submitting the information below, please take a moment
to review the requirements for submission.

1.  Was the Brother a Master Mason in the State of Illinois? Yes No
2.  If a widow has been identified, has contact been made to verify she is alive? Yes No

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Report Member/Widow Death

Type of death you are reporting  Brother Mason Widow

Full name of deceased - First MI   Last

Date of Birth     Date of Death

Lodge Name    Lodge Number

If decedent was the Member, does he have a widow?  Yes No Dont Know

Has the widow been contacted/verified as living? Yes No

If so please provide her name, current address and phone number

First Name    Last Name

Address   City   State   Zip 

Home Phone   Cell Phone

Name of person submitting this form (required)

Contact number

* Please note - It is first necessary to contact or verify the status of the widow prior to
   submission.  This aids the IMOS program in insuring that accurate information is being
   reported.  All information submitted will be reviewed by the IMOS program.