Bereavement Notification Form

Your Crosstown Chicago family will be honored to stand with you & your family when you lose a loved one. When you are facing bereavement, please notify us by completing this form. Our ministry team will reach out to serve you and gather additional information to facilitate our support of your family.

Today's Date

Your Name

Your Email Address

Your Mobile Phone Number

Name of Loved One/Deceased

The deceased is my:

Please select one option.

Husband Wife Father Mother Brother Sister Son Daughter Uncle Aunt Cousin Grandfather Grandmother Stepfather Stepmother Great-grandfather Great-grandmother Grandson Granddaughter Other

If other, please share your relationship to the deceased:

Is the loved one a Citizen of Crosstown?

Please select one option.

Yes No

Are you requesting a formal resolution?

Please select one option.

Yes No

If the deceased was a Crosstown Citizen, please upload their photo here:

Upload (8MB)

If the family has a preferred contact person (other than you), please share their contact information with us below:

Preferred family contact name:

Preferred family contact e-mail:

Preferred family contact phone:

Bereavement Notification Form

Description

Please Fix the Following