Death Notification

Please complete this form and press the SUBMIT button to send your Death Notification.  If your request is urgent, and you need to reach a pastor after hours or on a weekend, please call the (217) 877-9529, extension 150.  All other requests will be handled through our receptionist within 1 business day or you may call the church office. During during office hours, call (217) 877-9529, extension 0.  After hours, please use extension 150. 

  1. Please provide the following contact information:

    Submitter's Name
    Submitter's Work Phone (xxx) 123-4567
    Submitter's Home Phone (xxx) 123-4567
     Submitter's E-mail
    Enter the name of the deceased below: Enter the date of death below:

    		-- mm/dd/yy
    Visitation Date Time of Visitation:
      -- mm/dd/yy Start Time:       End Time:      
    Funeral Date Time of Funeral: Funeral End Time:      
      -- mm/dd/yy Start Time:      
    Funeral Location: Burial Location:  

  2. I have read the  Heartland Community Church Privacy Statement and intend this information to be considered . . .

  3. I have read the Heartland Community Church Privacy Statement  and agree/do not agree with its terms.

  4. Please list the names of family members attending Heartland:

Copyright © 2003 [Heartland Community Church]. All rights reserved.
Revised: 04/20/04