Today's Date* Member Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Payer First Last Individual paying for this membership (if different from Member name) Phone*Funeral Establishment*CLICK THE DOWN ARROW to select a funeral home ---------------------->**BRIDGES (Athens) - 706-543-2551BYARS (Cumming) - 678-455-5815DAHLONEGA (Dahlonega) - 706-864-3683**FISCHER (Chamblee) - 678-514-1000**GEORGIA CREMATION (Acworth) - 678-398-9266**GEORGIA FUNERAL CARE & CREMATION (Acworth) - 678-594-0043GOOLSBY (Atlanta)- 404-588-0128HARWELL (Covington) - 770-786-2524HIGGINS HILLCREST (Newnan) - 770-253-4723**HILLSIDE MEMORIAL (Clarkesville) - 706-754-6256HOLLY HILL (Fairburn) - 770-964-7833HUTCHESON MEMORIAL (Buchanan) - 770-646-3878INGRAM (Cumming) - 770-887-2388MCDONALD & SON (Cumming) - 770-886-9899**MEDFORD-PEDEN (Marietta) - 770-427-8447MOUNTAIN VIEW (Blairsville) - 706-745-3456PURVIS (Adel) - 229-896-2906ROY DAVIS (Austell) - 770-948-2552STARLING-EVANS (Harlem) - 706 556-6524STEWART (Lawrenceville) - 770-962-3100STEWART (Loganville) - 770-466-1544STEWART (Monroe) - 770-267-2594STEWART (Snellville) - 770-979-5010THOMAS L. CARTER (HInesville) - 912-876-5095TRI-CITIES (Lithonia) - 770-482-2358WAGES & SONS (Lawrenceville) - 770-277-4550WAGES & SONS (Stone Mountain) - 770-469-9811**WHEELER (Covington) - 770-786-7111>>Admin only<<You MUST choose a funeral home in order to continue with the application process. Note that the funeral homes designated with asterixes are the "Preferred Providers," who offer all MSOG plan options at the lowest contract rate. Relationship to Member of Person Completing FormMember's Birth Date MM DD YYYY Type of Arrangements DesiredDirect CremationDirect Cremation with Memorial ServiceDirect BurialDirect Burial with Graveside ServiceComplete FuneralFor a detailed overview of arrangement choices, please see the "Funeral and Cremation Services" page linked on the menu on left. Note that prices for choices other than “Direct Cremation” and “Direct Burial” are guaranteed at Memorial Society reduced rates ONLY from the Preferred Providers (asterixed on the previous page), and may be substantially higher from the other Funeral Directors.Types of Rites (optional)Memorial (without body)Funeral (with body)Unknown at this timeNoneDetails Please provide appropriate details, such as disposition of ashes, location of rites (if any), name of religious organization, name of clergyman, music, cemetery location, veteran status, etc.I WISH TO DONATE my body to the closest medical teaching facility.YesNoFor organ donation, register at donateLIFEgeorgia.org.Please give the name, address and telephone number of the person responsible for your disposition (other than your spouse). To aid you in making this determination, this is the order of legal next-of-kin: Adult child, parent, brother or sister, other relative, executor or guardian of property.Person Responsible for Disposition (other than spouse) First Last PhoneThis Person's Relationship to MemberStreet Address Street Address City State / Province / Region ZIP / Postal Code # of Child under the age of 18.No additional chargeApplication Fee* Price: $35.00 By pushing the submit button, you will be taken to a payment page, processed by PayPal, where you may pay with a credit card, debit card, or PayPal account balance.