Reflections Grave Groomers Holiday Wreath order form

Christmas Wreath Order Form www.reflectionsgravegroomers.com mail with a check or money order to: Reflections Grave Groomers 12230 W Chief Lake Road Hayward, WI 54843
Type of wreath (please circle one) $30.00 25" balsam wreath 25" balsam cross 36" balsam cross Name of deceased_____________________________________ Date of birth and death (if known)______________________ Cemetery name _____________________________________ City _______________________________________________ Lot & Section or brief directions to gravesite. (if known) _____________________________________________________ _____________________________________________________		Additional wreaths to same cemetery $25.00 each 25" balsam wreath 25" balsam cross 36" balsam cross Name of deceased_____________________________________ Date of birth and death (if known)______________________ Cemetery name _____________________________________ City _______________________________________________ Lot & Section or brief directions to gravesite. (if known) _____________________________________________________ _____________________________________________________
Your name__________________________________________________________ Address____________________________________________________________ City/State/Zip_______________________________________________________ Daytime Telephone Number____________________________________________ e-mail address(used only for picture delivery or questions on wreath placement) _________________________________________________________________ We accept: Visa MasterCard Discover American Express Check or Money Order (please circle one) Credit Card Number___________________________________________________ Expiration Date____________ CSC________ (For MasterCard or Visa, it's the last three digits in the signature area on the back of the card) (For American Express, it's the four digits on the front of the card.)