If your department has had a member pass away in the last calendar year (Jan 01 - Dec 31) please fill out the form below.

This form should be filled out by Department President, Department Chief or Department Chaplain.

Indicates Required Field

Member Name:
Member Department(s) : (Select ALL that Apply)		Bay District VFD Bel Alton VFD Benedict VFD & RS Bryans Road VFD Calvert Advanced Life Support Calvert County Rescue Dive Team Charles County Dive Rescue Charles County MICU Charles County Volunteer Rescue Squad Cobb Island VFD & EMS Dentsville Volunteer EMS, Fire, and Auxiliary, Inc. Dunkirk VFD & RS Hollywood VFD Hollywood VRS Hughesville VFD & RS Huntingtown VFD & RS Indian Head VFD & RS Ironsides VRS La Plata VFD Leonardtown VFD Leonardtown VRS Lexington Park VRS Mechanicsville VFD Mechanicsville VRS Nanjemoy VFD Newburg VRS & FD North Beach VFD & RS Potomac Heights VFD & RS Prince Frederick VFD Prince Frederick VRS Ridge VFD Ridge VRS Second District VFD & RS Seventh District VFD Seventh District VRS Solomon’s VRS & FD St. Leonard VFD & RS St. Mary's County ALS Tenth District VFD & RS Waldorf VFD
County:		Calvert County Charles County St. Mary's County
Date of Death:
SMVFA Office(s) Held: (Select ALL that Apply)		President 1st Vice President 2nd Vice President Secretary Treasurer Chaplain Assistant Chaplain LA - President LA - 1st Vice President LA - 2nd Vice President LA - Secretary LA - Treasurer LA - Chaplain LA - Assistant Chaplain LA - Guard
Positions held in department: (Select ALL that Apply)		1st Vice President 2nd Vice President Assistant Chaplain Assistant Fire Chief Assistant Secretary Assistant Treasurer Associate Member Auxiliary Member Auxiliary President Auxiliary Secretary Auxiliary Treasurer Auxiliary Vice President Battalion Fire Chief Board of Director Captain Chair of the Board Chaplain Charter Member Chief Engineer Community Board of Director Corresponding Secretary Deputy Fire Chief District Fire Chief Driver / Engineer EMR EMS Assistant Chief EMS Battalion Chief EMS Captain EMS Chief EMS Deputy Chief EMS District Chief EMS Lieutenant EMS Sergeant EMT EMT-I EMT-P Fire Chief Fire Marshal Firefighter Firefighter / EMT First Engineer Honorary Member Lieutenant Life Member Member Paramedic Parliamentarian President Public Information Officer Recording Secretary Safety Officer Secretary Sergeant Sergeant at Arms Supply Officer Training Officer Treasurer Trustee Vice President Water Supply Officer
Member Type:		Active Member Associate Member Auxiliary Member Honorary Member Life Member Retired/Past Member
LODD:		No Yes
Please attach current picture to be displayed at Memorial Service:		Add files...
Member Submitting:
I authorize publication of the enclosed memorial information in the SMVFA Memorial Service Program:		No Yes
Notice: By submitting this form, the individual authorizes publication of the information in the SMVFA Memorial Service Program.