Order one tablet for:                                                                            Reserve one tablet for:

 

     Name:____________________________                          Name:_____________________________  

              First                          M.I.                                    Last                                               First                              M.I.                                 Last

 

     Date of Death: _________________________                                          “Reserved” plaque will be installed.

 

 

   Send Notification to:

     Name:____________________________                   Please list additional names and addresses on reverse side.

 

     _______________________________________________________________

     Street                                       City                        State                  Zip

                                 

                                      

 

 

  £ Check or £ Visa/MasterCard #___________________________ Exp. date __/__/__