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name:


jma#:


former address:


new address:


current e-mail:




other My wife and I built an Amazon affiliate

child's birth date:


child's full legal name:


child's birth order:

(whether 1st, 2nd, 3rd, etc. child born to you)

child's city/state of birth:


name of mother:

(include jma # if you have it)

name of father:

(include jma # if you have it)

parents' address:

(to receive child's family member certificate)


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marriage date:


city/state where married:


full name of bride or partner a:

(include jma # if you have it)

full name of groom or partner b:

(include jma # if you have it)

birthdate:


birthplace


newlywed's address:

(to receive spouse's family member certificate & welcome letter)


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death date:


name:

(include jma # if you have it)

city/state of death:


city/state of internment:

(include cemetery name if you know it)

city/state of cremation:


disposition of cremains:


if you have an obituary you would like published in our journal, please send it to juanita goin at juanitagoin@hotmail.com.

submitted by:

(please give name & contact information)

today's date: