GENERATION GARDEN BRICK FORM
SHRINE OF OUR LADY OF THE ISLAND, PO BOX 26, EASTPORT, NY 11941
Paternal Grandfather’s First Name
Paternal Grandfather’s Last Name
Paternal Grandmother’s First Name
Paternal Grandmother’s Maiden Name |
Maternal Grandfather’s First Name
Maternal Grandfather’s Last Name
Maternal Grandmother’s First Name
Maternal Grandmother’s Maiden Name
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Father’s First Name
Father’s Last Name
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Mother’s First Name
Mother’s Maiden Name
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Your Name (First-Middle-Last –option-Maiden)
Donor:____________________________________________________________ Tel #:________________________
Address:_________________________________________________________________________________________
City:________________________________________________________ State:_________ Zip:_____________
Complete Brick Order Form and enclose $200 for each brick. Checks payable to: Shrine of Our Lady of the Island.
DATE:_________________ PAID:__________ CASH/CHECK #:____________ STAFF/VOL INITIALS:________
BEIGE PAPER Laser Impressions Order Date:____ Admin/Memorials/Generations/Brick Form/11-08-07