Obituary Submit 10/4/2022

Families may use this form to submit preliminary obituary information to Butzin-Marchant.   Please fill in as much information as you can and click the "Submit" button on the bottom.  We will pre-fill the forms and prepare a preliminary obituary for you to review when we meet in person.

* = Required Information

Survivor / Contact Information
Please identify who is submitting this information so that we may contact you if we have any questions.
*Contact Name:
*Contact Phone:
*Contact Address:
*Contact City:
*Contact State:
*Contact Zip:
*Contact EMail:
Full Name of Deceased
*First Name:
Middle Name:
*Last Name:
*Age:
*Address:
*City/Town/Village:
*State and Zip Code:     
*County:
*Soc Sec No.:
Died When & Where:
Died Where - City/Town/Village:
Died Where - State:
*Died Where - County:
*Birth Date:
Birth Place:
Birth City/Town/Village:
*Birth State:
*Father's Name:
*Mother's Name (Maiden):
Place of Education:
*Years Completed:
*Occupation:
*Business/Industry:
How Long:
   
*Residence:
*Marriage, whom, when, where:
*Divorced: Yes      No
  Widowed: Yes      No
Previous Spouse(s):
Member of (clubs, churches,...):
*Military: Yes     No     Unknown
Military Service Record
Branch / When Served:
(Bring honorable discharge
papers - DD214 form)
Flag: Folded     On Casket
*Hispanic: Yes      No
*Race:
Survivors and Their Location
Please list the names and locations of the 
survivors (spouse, children, brothers and sisters, grand children).
Relationship Name City State
Preceded in death by:
Funeral Arrangements
(1) Visitation Date & Time:
(1) Visitation Place:
(2) Visitation Date & Time:
(2) Visitation Place:
Funeral/Memorial Location:
Funeral/Memorial Date:
Funeral/Memorial Time:
Clergy:
Cemetery:
Memorials To:
Pallbearers:
Who Calls Pallbearers: Funeral Home        Family
Lunch: Funeral Home        Family
Lunch Location:
Music: Funeral Home        Family
Songs:
Flowers: Funeral Home        Family
Flower Type:
Hairdresser:
Media: Ripon     Oshkosh     Fond du Lac    
Berlin Journal    WRPN
Other: 
*Certified Copies of Death Certificate:
Notes:

(Please use this area for any extra comments or information)
*Submit Information? Enter 'Yes' to send us your obituary information

All information is kept in the strictest confidence.

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   515 Mayparty Drive
   Ripon, Wisconsin USA, 54971

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