NORTHERN MICHIGAN UNIVERSITY
DEATH NOTIFICATION

Date:_______________

AFFILIATION (check one):

_______ Employee - Faculty
_______ Employee - Staff
_______ Retiree (Emeritus: _______yes________no) 

Name of Deceased:____________________________________________________
                                                            First               MI               Last

Name of Surviving Spouse_______________________________________________
or Next of Kin:                                        First               MI               Last

Date of Death (or approximate date):_______________________________________

Position Title:_________________________________________________________

Department:__________________________________________________________

Reported by:______________________________________ to Human Resources.
(name of Department Head)

The following offices have been notified by telephone (check all that apply):

______ President's Office

______Vice President for Academic Affairs

______ Vice President for Finance and Administration

The following offices will receive a copy of this notice:

President's Office
Vice President for Academic Affairs
Vice President for Finance and Administration
Communications and Marketing
Financial Services
NMU Foundation and Alumni
Retirees Association (if applicable)
AdIT
Academic Information Services (AIS)

9/5/07