Sex *

Male

Female

Date of Birth *

MM

DD

YYYY

Marital Status *

Married

Divorced

Married but Separated

Widowed

Never Married

Unknown

Did they ever serve in the military? *

Yes

No

Deceased Residence *

(Street and Number, City, State, Zip code)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Inside city limits? *

Yes

No

Father's Name *

(or "Unknown")

First Name

Last Name

Mother's MAIDEN Name *

(or "Unknown")

First Name

Last Name

Informant *

First Name

Last Name

Informant's Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Publish free Death Notice in Champaign News Gazette?

Yes

No