"MEMORIAL REQUEST PAGE"

First Name: Last Name:

Address: City: State: Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Deleware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louesiana Maine Maryland Massachusetts Micigan Minnesota Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennselvania Rhode Carollina South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wesconsin Wyoming

ZIP Code: Country:

Telephone Number: Alternate Telephone Number:

Email:

Confirm Email:

DECEASED INFORMATION

First Name: Last Name:

Nick Name: Age at Death: Gender: Select Female Male

Date and Place of Birth:

Date and Place of Death:

Do you have pictures?: Select Yes No How many?: (You can have up to 5)

Would you like me to write a poem?: Select Yes No

Short Biography (Interests, Hobbies, Organizartions, Religion, Family Members Etc.) of Deceased:

 

TREASURES OF CHARM PRIVACY POLICY:

I'd like to assure you of your absolute privacy.

All information is kept strictly and absolutely confidential. No names and / or addresses on this list have ever been released in ANY form to ANY source for ANY reason at ANY time and they never will be.

If you have ANY further concerns please e-mail me "Jeni" and I will address your concerns promptly.

With Love, Light and Peace

Jeannie

 

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