Form
Sierra's Haven
Memorial Brickway

Bricks are $25.00 (4" X 8"), three lines of 13 spaces are available for engraving.  Symbols are $1.00 each.  Dog bone takes 3 spaces, paw print and cat head take 2 spaces each.

Please fill in blocks below exactly as you want it to appear, drawing in the symbols where they should be located. 
Mail your completed form to : Del Vastine
                                              1312 Altamont
                                              Portsmouth Oh. 45662

YOUR NAME_____________________
PHONE NO._________________
Please include payment
check
check
check
Print this form, fill it out and mail it in.