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Memorial Submission Form
Name of person or pet being memorialized
Your statement
I give permission for and own the rights to allow publication of any photos and/or statements submitted for the memorial page
I allow publication
Person submitting form
Mailing address of person submitting form: street, city, state and zip code
Method of Payment $18.50
Check in mail
Credit Card called into office at 515-827-5700
Cash brought into office
www.Paypal.com Payable to Immydog@msn.com
Phone number of person submitting form
Email address of person submitting form
Photo submission will be
Email
Sent by postal mail
Dropped at the office
