Sierra Hospice
"Making Final Moments Matter"

DONATION FORM

Item Description Qty. Price

Subtotal

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                                                                    Order Total:______________

Name __________________________________________________________
Address_________________________________________________________
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Phone___________________________________________________________

In Loving Memory of:

 

Name as you would like it to appear on the plaque.
Please print clearly.

Check Amount $____________________________ Check #______________

Signature________________________________________________________

Please make your check payable to Sierra Hospice and send it along with this form to the address below or stop by our office.
 

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Sierra Hospice
150 Brentwood Drive  •  P.O. Box 95  •  Chester, CA 96020
Phone: 
530-258-3412  •  Fax: 530-258-3001
email at 
sierrahospice@frontier.com

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