Date: In Memory of [PDF]

Book(s) (Specific Title(s) or Subject(s)):. __. 2. Equipment: __. 3. Furniture: ____. 4. Librarian's Choice: __. 5. Othe

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Date: ______________ In Memory of: ______________________________________________________________________ __________________________________________________________________________________ Notification of Memorial To: (Relative or Friend of Deceased) NAME: ________________________________________________________________________ ADDRESS: _____________________________________________________________________ CITY: _________________, STATE: _______________ ZIP: ________________ PHONE: ( ___ ) ________________________________ AMOUNT DONATED: $ ___________ In Cash: ________ or Check #: _______________ For the Purchase of: 1. Book(s) (Specific Title(s) or Subject(s)): ___________________________________________ __________________________________________________________________________ __ 2. Equipment: __________________________________________________________________ __________________________________________________________________________ __ 3. Furniture: ____________________________________________________________________ ________________________________________________________________________ ____ 4. Librarian's Choice: ____________________________________________________________ __________________________________________________________________________ __ 5. Other (Specify): _______________________________________________________________ ___________________________________________________________________ _________ DONATION GIVEN BY: Name: _________________________ Address: _________________________ City: _________________________ Phone: _________________________

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