Full Name:

Cullum Number and Class year:

Date of Birth:

Date of Death:

Place of Death:

Remains are (complete one):

Interred in:

Cremated / Inurned in:

Cremated / Ashes scattered in:

Next of Kin:

Relationship:

Address:

City:

State:

ZIP:

E-mail:

Fax:

NEXT OF KIN, PLEASE CHECK AND SIGN ONE OF THE FOLLOWING:
 
  Approval for publication in official AOG printed publications ONLY
 
Signature:

  Approval for publication in official printed publications and non-password-protected class web page
 
Signature:

Additional copies of the issue in which the memorial is published?
 
(First two are complimentary, extra copies are $5 for the first copy and $3 for each additional copy. Please enclose payment with Inventory Sheet and Memorial. Check, Visa, Mastercard, and American Express are accepted.)

# of additional copies:

Total amount:

Credit Card Number:

Exp. Date:

Author of Memorial Article:

Relationship to Deceased:

Cite the author(s) name at the bottom of the article?