I want the Name Plate at $27.50
(Please fill out the below information)

In Memory or Honor of _______________________________________

Dates __________________

From __________________

Name of Plant _____________________________

EXAMPLE

In Memory of our Mother

1917 – 2004

From her Children

Name: __________________________________________________

Address: ________________________________________________

City: _____________________ State: _______ Zip: ______________

Total Amount Paid: $_____________________   Cash _____   Check _____

Attached: