Family Death Notification

This form is to be used for Family Death Notification ONLY, if you would like to report an Illness, please CLICK HERE!
If you have questions about this, you can call us at 404-768-2626. We at East Point Flower Cottage thank you for your continued support.
*Indicates a required Field

Date Of Notice: *

Please Select: *

Name of Deceased: *

Relationship to Employee: *

Employee Name: *

Employee Number: *

Department: *

Station: *

Title: *

Home Street Address: *

Apartment Number:

City: *

State: *

Zip: *

Home Phone Number: *

Date of Funeral: *

Funeral Home: *

Funeral Home Address: *

Funeral Home Phone Number:

City: *

State: *

Zip: *

Your Name: (Must be a Supervisor or Manager) *

Your E-mail: *

Confirm E-mail: *

Your Work Number: *

Additional Comments:

Flower Cottage On Main

404-768-2626