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<div class="control-group ticket_section"> <label class=" required control-label old_mailing_address_747413-label " for="helpdesk_ticket_old_mailing_address_747413">Old Mailing Address</label> <div class="controls "> <textarea class=" required paragraph section_field span12" rows="6" placeholder="" name="helpdesk_ticket[custom_field][old_mailing_address_747413]" id="helpdesk_ticket_custom_field_old_mailing_address_747413"> </textarea> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label new_mailing_address_747413-label " for="helpdesk_ticket_new_mailing_address_747413">New Mailing Address</label> <div class="controls "> <textarea class=" required paragraph section_field span12" rows="6" placeholder="" name="helpdesk_ticket[custom_field][new_mailing_address_747413]" id="helpdesk_ticket_custom_field_new_mailing_address_747413"> </textarea> </div> </div>
<div class="control-group ticket_section"> <label class=" required control-label deceaseds_name_747413-label " for="helpdesk_ticket_deceaseds_name_747413">Deceased's Name</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][deceaseds_name_747413]" id="helpdesk_ticket_custom_field_deceaseds_name_747413" /> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_dob_747413-label " for="helpdesk_ticket_cf_dob_747413">Deceased's Date of Birth (Ex. MM/DD/YYYY)</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_dob_747413]" id="helpdesk_ticket_custom_field_cf_dob_747413" /> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_deceaseds_date_of_death_747413-label " for="helpdesk_ticket_cf_deceaseds_date_of_death_747413">Deceased's Date of Death (Ex. MM/DD/YYYY)</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_deceaseds_date_of_death_747413]" id="helpdesk_ticket_custom_field_cf_deceaseds_date_of_death_747413" /> </div> </div>
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