	Wednesday, June 19th, 2013

1700 Galloping Hill Road
Kenilworth, New Jersey
07033-1303

Phone (908) 620-1871
Toll Free 1-800-852-0137
Fax (908) 620-1874

Notice of Death

Below is Web Site form 300 to send a "NOTICE OF DEATH" to the New Jersey State Firemen's Association. Please complete the form in it's entirety and click the send button only once.

If you have any questions regarding this form please call the New Jersey State Firemen's Association at: 1-800-852-0137 or 908-620-1871.

NOTE: Notice of Death should be forwarded to office within (30) days of death.

Association #:
Company #:
Line #:
Date:

Advisory Committee
New Jersey State Firemen's Association
1700 Galloping Hill Road
Kenilworth, New Jersey 07033-1303

Gentlemen:

I beg to report the death of a member of our Association with the information as follows:

Name
Date of Death
Date of Birth
Address of Deceased - Street
City, State
County
Zip Code
Name of Fire Company
Date of Admittance
Date of Retirement
Line of duty ( Must be Documented)	Yes
Name of widow(er)
Address of widow(er)
Names and Addresses of Children 1 Line per Child
Names and Addresses of Relatives 1 Line per Relative
Relief Association
Secretary's name
Signature of Secretary	(Check)
Secretary's Address
Secretary's Email Address
Response Email Address	Response email not in required format.
If you want an email response enter your address in the field above.

*****IMPORTANT*****
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