ST. FRANCIS CHAPEL
5172 Gregory Rd. #8, Greenback, TN 37742
fatherdaveh@gmail.com
(423)-295-4156 stfrancismission.wixsite.com/chapel
Rt. Rev. Fr. David Hawkins, Jr., FSIA, Pastor
FORM FOR RELEASE OF SACRAMENTAL RECORDS
Today's Date: _____________
Requestor: ___________________________________________
Phone: _____________________
Address: ________________________________________________________________
or Proxy:_________________________________ Relation: spouse/guardian/child/other____________
(if different) Phone: _____________________
Address: ________________________________________________________________
SACRAMENT/s (Circle) Baptism, First Communion, Marriage, Other:_________________________
Name at Sacrament: __________________________________ Date of Sacrament: ______________
Date of Birth: __________________ Place of Birth: _______________________________________
(if different) Church of Baptism: __________________________________________
Demonination: __________________________________
Address: ________________________________________________________________
Name of Father: ___________________________________________________________
Name of mother, with Maiden name: _____________________________________________________
Date of Marriage: _____________________ Spouse's Name: ___________________________________
St. Francis Pastor's Sig:______________________________________ Date: _____________
I, request, personally or by proxy signing in my presence. Permit St. Francis to release the requested records be sent to the noted Parish. Parishes noted are not liable for their damage or loss in transit.
Recieving Parish: ________________________________________________________
Pastor: __________________________________________ Phone: __________________
Address: _________________________________________________________________
Requestor or Proxy's Sig.: _____________________________________ Date: ___________
(Proxy: parent, spouse, adult children or Duly authorized person appointed by the requestor)