Level II Obituary Form

Please fill out the following form to have your loved one's obituary published in the Kingman Leader-Courier and KCNOnline.com. There is a $50 charge for publication due upon submission of this form. You can pay online by credit card.

Contact Information

Please provide us with your contact information in case we need to get in touch with you prior to publication.
Your Name Your Name * First Last
Phone Phone * - ### - ### ####
Email
Obituary Information

Please provide us with the information you would like to have published in the obituary.
First Name *
Middle
Last *
Nickname
Date of Birth Date of Birth * / MM / DD YYYY
Date of Death Date of Death * / MM / DD YYYY
Place of Birth
Place of Death
Spouse Surviving

Spouse Surviving Yes No
Spouse's Name Spouse's Name First Last
Parents Suriving

Parents Suriving Mother Father Both
Mother's Name Mother's Name First Last
Father's Name Father's Name First Last
Surviving Children (Spouses)

Please provide the name of surviving children (spouses) and where they live.
Surviving Siblings (Spouses)

Please provide the name of surviving siblings (spouses) and where they live.
Preceded in Death by Children

Please provide the name of children that preceded in death.
Preceded in Death by Siblings

Please provide the name of siblings that preceded in death.
Number of grandchildren
Number of great-grandchildren
Number of great-great-grandchildren
Church Membership

What church were they a member of if any.
Occupation
Years of Service
Name (Only) of Club/Organization Membership
Verteran

Verteran Yes No
Drop Down
War Veteran

Which war(s) did they serve in if any?
Funeral Services

Please provide the date, time and location of funeral services and burial location.
Place of Funeral/Memorial Service *
Address of Funeral/Memorial Service Address of Funeral/Memorial Service *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Service Date of Service * / MM / DD YYYY
Time of Service Time of Service * : HH MM AM/PM
Name of Cemetery
Cremation

Cremation Yes No
Accepted Memorial Contributions
Funeral Home Information

Please provide the information on the funeral home in charge of arrangements.
Name of Funeral Home *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone * - ### - ### ####
Email
Photo Upload

Attach Files

Please upload the photo of your loved one that you want published with the obituary.
$0

Total

Level II Obituary Form

Level II Obituary Form

Contact Information

Obituary Information

Funeral Services

Funeral Home Information

$0

Total

$`0`