Please print this form, fill it out, and deliver to the Village Church office.  You can also e-mail your memorial announcement and photos to .

Personal Information

Name of deceased: _____________________________________________________________

Date of birth: _________________________  Date of death: ____________________________

City and state of birth: __________________________________________________________

Personality or attributes of this resident:  ____________________________________________

_____________________________________________________________________________

Did resident serve in military? If yes, which branch: ___________________________________

Memorial Service Information

Date/Time/Location of service: ____________________________________________________

Marriage Information

Name of (first) spouse: ________________________________________________________

Is (first) spouse still living?  Yes (   )      No (   )

Date married or length of marriage: _______________________________________________

Did resident remarry? Yes (   )      No (   )

If resident was remarried, please give additional information:

Name of (current) spouse: ________________________________________________________

Is (current) spouse still living?  Yes (   )      No (   )

Date married or length of (current) marriage: _________________________________________

Family and Children

Names of children (if available): ___________________________________________________

_____________________________________________________________________________

Number of grandchildren: ____________________

Number of great-grandchildren: ________________

Shell Point Information

Year resident moved to Shell Point: ____________      Court: ___________________________

Did resident reside in King's Crown or The Pavilion? __________________________________

General activities and interests at Shell Point, including church or volunteer activities: ______________________________________________________________________________

______________________________________________________________________________

Contact Information

Contact name: _________________________________________________________________

Contact phone number: __________________________________________________________

Contact address: (complete address if not Shell Point resident): __________________________

Relationship with deceased: _______________________________________________________

Any other information you'd like to provide: _________________________________________

_____________________________________________________________________________

I hereby consent to the publication, airing, or use of this information and any accompanying photographs by Shell Point Retirement Community.

__________________________________

                    (Signature)

Back to Memorials & Remembrances

To remember your loved one on www.shellpoint.net, send your written remembrance, as well as any photos, to . You can also send them to The Village Church, attn: Remembrances, 15100 Shell Point Blvd., Fort Myers, FL 33908.  If you wish your photos returned to an address outside Shell Point, please supply a self-addressed stamped envelope.