Last Rites Request

Last Rights Request Form

Person Requesting Last Rites

Prefix

First Name *

Middle Name

Last Name *

Age *

Anything we should know about the person receiving last rites?

Point of Contact Information

First Name *

Last Name

Phone *

Relationship to person receiving last rites *

Location Where Last Rites Will Be Performed

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

If the person receiving last rites is in a Nursing Home or Hospital, please provide the room number.

Time and Date Last Rites are Needed

Date *

Hours *

Minutes *

EST

Archangels of Liberty
P.O. Box 231
Jamison, PA 18929

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