Chalice Placement Form · Assembly 1087

When a Sir Knight of our assembly dies, a chalice or ciborium is presented in his memory to a Catholic priest, church or mission, so that he is remembered in prayer whenever it is used. This form records your wishes so your family and the assembly know your intentions at a difficult time.

Under Article X of the assembly by-laws the placement is selected by your family or the assembly. This form tells them what you would want, so that their choice can honour it.

Sir Knight’s information

First name *

Middle initial

Last name *

K of C member no.

Council no.

Pick from the list or type it.

Date of birth

Street address

City

State

ZIP

Phone

Email

Placement wishes

1. I would like my sacred vessel to be a

Chalice Ciborium No preference

2. I would like it presented to a Catholic

Priest Church Mission Let my family or the assembly choose

Name of priest, church or mission

For a priest, his parish too if you know it.

Recipient street address — if you know it

City

State

ZIP

Recipient phone — optional

Please answer yes or no

3. Is the priest, church or mission aware of your intentions?

Yes No

4. Would you like the Fourth Degree Color Corps to take part in your funeral services?

Yes No

5. May the assembly contact your Lady or family to carry out your wishes?

Yes No

6. Is your Lady or family aware of your intentions?

Yes No

Family contact name — optional

Relationship

Family contact phone

Family contact email

Anything else we should know — optional This replaces a placement form I sent before.

Your form goes straight to the assembly’s records officer and is used only for the chalice program.

We could not save your form just now. Please email it to us instead, or copy the text below and send it to with the subject “”.

Chalice / Ciborium Placement Request

Sir Knight’s information

Placement wishes

Please answer yes or no

Thank you