Report of Sickness
and Distress
Please report Moose Sickness and Distress by completing this
information form so that we can post it as soon as possible
Your IP Address is being stored to prevent abuse
 
Name of Member Sick or Deceased:
Is Above a Lodge or Chapter Member?
Select Highest Degree Held if any:
Lodge/Chapter Name Where Member:
Lodge/Chapter Number Where Member:
Please Provide Details of Distress Report:
   
Please Provide Information for Members to send Cards:  
Mail Card to:
 
Name:
Address:
Address:
City:
State:
Zip:
   
If Death, Please Provide Funeral Details: NOTICE:
A Death Notice WILL NOT BE POSTED without
complete information (Funeral Home,
Visitation, Funeral, etc).
If you do not have this information,
do not submit report
   
Date of Death:
Funeral Home Name:
Funeral Home Address:
Funeral Home City:
Funeral Home State
Funeral Home Zip:
Funeral Home Phone:
   
Visitation Details  
Visitation Date(s)
Visitation Hours
   
Funeral Details  
Funeral Date
Funeral Hours
 
Moose Service Details
 
Moose Service Date
Moose Service Time:
   
Please Provide Your Information
NOTE: NOTICE WILL NOT BE POSTED WITHOUT YOUR NAME AND A VALID EMAIL ADDRESS 		 
My Name Is:
My E-Mail Address Is:
   
 
   

 
     
 
           
 

 

 
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Contact Us:
Regional Manager - Dwaine Brown
State Secretary - John Sipes
Webmaster - Steve Speaks		 IMPORTANT NOTICE: The Loyal Order of Moose is a private organization. All activities and events referred to on this Web site and in the Moose newsletters published herein are available to members in good standing and their qualified guests only. This Web site is for informational purposes with proprietary information intended for members only. General information is available to the public at large, but should not be construed to be a solicitation for membership. This Web site is an initiative of the Ohio State Moose Association, and is not sanctioned by the Loyal Order of Moose, Moose International or any subsidiary thereof. All logos, trademarks and servicemarks pertaining to the Loyal Order of Moose and/or its programs or degrees are copyrighted © by Moose International, Inc., Mooseheart, Illinois.
 
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Galion, OH 44833