EmailMe Form - ALSO - DO NOT USE THIS FORM

Social Security # *

Last 4 of members SSN ####

Requesting Individual's Name *

First Last

Contact Information of the Onsite Director

Requestor's Email *

Work Phone *

### - ### - ####

Cell Phone *

### - ### - ####

Please provide number of actual onsite representative.

Memorial Service Location Requested *

Please select the type of location for the service. Be advised that the use of the "21 Gun Salute" may be restricted due to the location selected.

Memorial Location

Please type in the actual address of the memorial event if not at Crown Hill National Cemetery. Use commas to end each portion of the address.

IMMHG Services Requested *

Eulogy w/Full Team

Eulogy w/Rifles Only

Eulogy w/Taps Only

Memorial Service Date & Time. Please use the calendar located between the date and time to pick the date. *

MM / DD / YYYY HH : MM AM/PM

Enter the date and time of the services at the above location.

Day of week *

Time for the Military Honors *

HH : MM AM/PM

Enter here the approximate time that the Military Honors portion of the service is to take place. IMMHG normally arrives 30 minutes prior.

Military present *

Have you requested service members branch be present at this service? Once they confirm attendance, please email scheduler@immhg.org

Mission number

Enter the mission number assigned by the military if or when you speak with them.

Deceased Name *

First MI Last

Grade, Rate, Rank from DD 214

Branch of service *

Remains *

Casket

Memorial

Urn

How are the remains presented at the service?

Flag Provided? *

Yes

No

Will there be a US Flag present for the service? It is your responsibility to have a flag on site. IMMHG cannot provide the burial flag.

Indiana County? *

Obituary web address (URL)

Copy and paste the web address for the obituary

Obituary

Copy and paste the obituary into this area.

Special request

Please enter here any information that would be helpful for the IMMHG team and the Military to know in fulfilling your request for services. Please use commas as the line spacer rather than paragraph returns.

DD 214 or Certificate of Honorable Discharge or VA card image file *

Choose the name of the file that is the scanned image of the deceased's DD 214 or Certificate of Honorable Discharge or VA card. Must be a .gif, .jpg, .jpeg, or .pdf file type.

Verification *

PLEASE VERIFY ALL INFORMATION. Your request is being processed. DO NOT press the submit button more than ONCE. An email acknowledging receipt in the system will be sent to you in a few minutes. Please check your SPAM FOLDER if you do not see it.