Untitled

<?php
    $to = "timothyjturner@gmail.com"; // this is your Email address
    $from = "email@franklincountyloss.org"; // this is the sender's Email address
    $first_name = $_POST['First_Name'];
    $last_name = $_POST['Last_Name'];
    $subject = "Deceased Information Form submission";
    $message = $first_name . " " . $last_name;

    $headers = "From:" . $from;
    $return = wp_mail($to,$subject,$message,$headers);
    if($return == TRUE){echo "Mail Sent. Thank you";}
	echo $return;

?>

<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<title>Deceased Information Form</title>
<style type="text/css">
#form1 fieldset {
	font-family: Lucida Sans Unicode, Lucida Grande, sans-serif;
}
.a {
	font-family: Lucida Sans Unicode, Lucida Grande, sans-serif;
}
#form2 p {
	font-family: Lucida Sans Unicode, Lucida Grande, sans-serif;
}
#form1 {
	color: #0E7D40;
}
body {
	background-color: #F4DEC0;
}
.a {
	color: #0E7D40;
}
.a strong em {
	color: #000;
}
.b {
	color: #FFF;
}

input[type=submit] {
    background:url("http://franklincountyloss.org/site/wp-content/themes/3clicks-child-theme/images/ButtonUP.jpg");
    border:0;
    display:block;
    height: 50px;
    width: 180px;
}

input[type=submit]:hover {
    background:url("http://franklincountyloss.org/site/wp-content/themes/3clicks-child-theme/images/ButtonDWN.jpg");
    border:0;
    display:block;
    height: 50px;
    width: 180px;
}
</style>

</head>

<body>
<form  method="post" action="" id="form1" enctype="text/plain">
<fieldset>
<table width="398" border="0" align="center" cellpadding="5">
  <tr bgcolor="#B1586C">
    <td width="384" scope="col"><div align="left">
      <h3>
        <legend class="a"><strong><em>Deceased Information</em></strong></legend>
</h3>
    </div>
      <p align="left" class="b">First Name
        <input name="First_Name" type="text" id="First Name" size="50" />
      </p>
      <p align="left" class="b"> Middle Initial
        <input name="Middle Initial" type="text" id="Middle Initial" size="5" />
      </p>
      <p align="left" class="b"> Last Name
        <input name="Last_Name" type="text" id="Last Name" size="50" />
      </p>
      <p align="left" class="b">
        <label for="Address">Address</label>
        <input name="Address" type="text" id="Address" size="50" />
      </p>
      <p align="left" class="b"> Apartment Number
        <input name="Apartment Number" type="text" id="Apartment Number" size="15" />
      </p>
      <p align="left" class="b"> City
        <input name="City" type="text" id="City" size="50" />
      </p>
      <p align="left" class="b">State
        <input name="State" type="text" id="State" size="5" />
        Zip
        <input name="Zip" type="text" id="Zip" size="15" />
      </p>
      <p align="left" class="b">
        <label for="Date of Death">Date of Death</label>
        <input type="text" name="Date of Death" id="Date of Death" />
      </p>
      <p align="left" class="b">
        <label for="Date of Birth">Date of Birth</label>
        <input type="text" name="Date of Birth" id="Date of Birth" />
      </p>
      <p align="left" class="b">
        <label for="Gender">Gender</label>
        <select name="Gender" id="Gender">
          <option value="Male">Male</option>
          <option value="Female">Female</option>
          <option value="Unknown">Unknown</option>
        </select>
      </p>
      <p align="left" class="b">
        <label for="Method">Method</label>
        <input name="Method" type="text" id="Method" size="50" />
      </p>
      <p align="left" class="b">
        <label for="Marital Status">Marital Status</label>
        <select name="Marital Status" id="Marital Status">
          <option value="Married">Married</option>
          <option value="Divorced">Divorced</option>
          <option value="Single">Single</option>
          <option value="Widow/Widower">Widow/Widower</option>
        </select>
      </p>
      <p align="left" class="b">
        <label for="Misc. Notes">Misc. Notes</label>
      </p>
      <p align="left">
        <textarea name="Misc. Notes" id="Misc. Notes" cols="50" rows="10"></textarea>
      </p></td>
  </tr>
  <tr bgcolor="#0E7D40">
    <td><div align="left">
      <h3>
        <legend class="a"><strong><em>NOK/Survivor Information</em></strong></legend>
      </h3>
    </div>
      <p>
        <label for="NOK First Name" class="b">First Name</label>
        <input name="NOK First Name" type="text" id="NOK First Name" size="50" />
      </p>
      <p class="b"> Middle Initial
        <input name="NOK Middle Initial" type="text" id="NOK Middle Initial" size="5" />
      </p>
      <p class="b"> Last Name
        <input name="NOK Last Name" type="text" id="NOK Last Name" size="50" />
      </p>
      <p class="b"> Address
        <input name="NOK Address" type="text" id="NOK Address" size="50" />
      </p>
      <p class="b"> Apartment Number
        <input name="NOK Apartment Number" type="text" id="NOK Apartment Number" size="15" />
      </p>
      <p class="b">
        <label for="NOK City">City</label>
        <input name="NOK City" type="text" id="NOK City" size="50" />
      </p>
      <p class="b"> State
        <input name="NOK State" type="text" id="NOK State" size="5" />
        Zip
        <input name="NOK Zip" type="text" id="NOK Zip" size="15" />
      </p>
      <p class="b">
        <label for="NOK Phone">Phone #</label>
        <input name="NOK Phone" type="text" id="NOK Phone" size="25" />
      </p>
      <p class="b">Alternate Phone #
        <input name="NOK Alternate Phone" type="text" id="NOK Alternate Phone" size="25" />
      </p>
      <p class="b">Relationship to Deceased
        <input name="NOK Relationship" type="text" id="NOK Relationship" size="50" />
      </p></td>
  </tr>
  <tr>
    <td><h3 align="left" class="a">
      <legend class="a"><strong><em>Other Helpful Information      for<br />
      LOSS to Support Survivors</em></strong>    </legend>
    </h3>
      <p>
        <label for="More Information">Additional Information<br />
        </label>
        <textarea name="More Information" id="More Information" cols="50" rows="25"></textarea>
      </p></td>
  </tr>
</table>
  <div align="center"><input type="Submit" name="submit" value=""></input></div>
  <input type="hidden" name="submitted" id="submitted" value="true" />
</form>
<p>&nbsp;</p>
</fieldset>
</body>
</html>