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 check one) $30.00 (tax included) 25" balsam_____ 25" cedar_____ 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 (tax included) 25" balsam_____ 25" cedar_____ 36" balsam cross _____ Name of deceased ______________________________________ Date of birth and death (if known)_________________________ 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 American Express Discover 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.)