Create a memorial or tribute
in the Mother of Mercy Outdoor Shrine

You may complete this form online or download a printable form to mail.

Memorial/Tribute Information

*Please select a memorial opportunity
Rays of Mercy Stained Glass Window ($250)
Granite Band ($500)
Marble Band ($1000)

*Name(s) to be etched:
[+] Add Another Name
[+] Add Another Name | [-] Remove
[+] Add Another Name | [-] Remove
[+] Add Another Name | [-] Remove
[+] Add Another Name | [-] Remove
[+] Add Another Name | [-] Remove
[+] Add Another Name | [-] Remove
[+] Add Another Name | [-] Remove
[-] Remove

Note: Up to 30 characters or spaces per line.

Total: $

Credit Card Information

*Card Number:

*Expiration Date
/

*Security Code

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Billing Information

Title

*First Name

*Last Name

Suffix

*Address

*City/Town

*State/Province

*Zip/Postal Code
-

*Country

*Email

*Phone