(801) 532-6479
MEMORIAL DONATION FORM
Date: _______________________________
Please use this form when making a Memorial Donation in honor of a deceased daughter. When this form is used, it it not necessary to send in another notice of her death. *Note: When sending in a donation in memory of someone who is not a member of the Daughters of Utah Pioneers (i.e. a husband or a neighbor, etc.), please enter the name in the space indicated below.
Memorial donation made in the name of : ______________________________________________
REGISTRATION NUMBER: _______________________ Date of Death: ______________
She was a member of CAMP: _______________________________________
COMPANY: ____________________ STATE OF: ________________
In her memory we are enclosing a donation in the amount of $_____________
Please send an acknowledgment to the donor:
DONATION IS FROM: NAME: ____________________________________________
(Name of person or group making donation)
C/O: ________________________________________________
(Name of person to whom acknowledgement is sent)
ADDRESS: ___________________________________________
CITY: _____________________ STATE: _____ ZIP: __________
FAMILY OF DECEASED: NAME: _____________________________________________
(Name of person or group making donation)
ADDRESS: ___________________________________________
CITY: ___________________ STATE: _____ ZIP: __________
SIGNATURE of person submitting form: ____________________________________________
If you feel an explanation is necessary, please attach additional pages if necessary.