HSLC Memorial Plaque Order Form

For people who want a visiting touchpoint, but do not have a need to house ashes, you may purchase a memorial plaque for the Memorial Wall, another feature of Holy Spirit’s Contemplative Garden. The plaque will include the engraved name(s) of one or two loved ones. A single-name plaque costs $400 and a double-name plaque (either Companion or Shared) costs $550. Click here for an example.

Items marked with an * are required.

Purchaser

First Name

Last Name

Phone

(###)

###

####

Address Line 1

Address Line 2

City

State

Zip Code

Memorial Plaque size

Single is for one person, Companion is for two persons with the same last name, and Shared is for two persons with separate last names.

Name to be engraved (on the top if Companion/Shared)

Print it exactly as you wish it to appear. Titles before or after the name are discouraged.

Date of birth (if known)

YYYY

Date of death (if known)

YYYY

Name to be engraved on the bottom (if Companion/Shared)

Print it exactly as you wish it to appear. Titles before or after the name are discouraged.

Date of birth (if known)

YYYY

Date of death (if known)

YYYY

If Companion, last name that will be shared between the two names

Next of kin/contact person #1

Name

First Name

Last Name

Relationship

(child, grandchild, family friend, etc.)

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Next of kin/contact person #2

Name

First Name

Last Name

Relationship

(child, grandchild, family friend, etc.)

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Next of kin/contact person #3

Name

First Name

Last Name

Relationship

(child, grandchild, family friend, etc.)

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I confirm that I am a past or present member of Holy Spirit Lutheran Church, or a member of the immediate family of a past or present member, such as a spouse, parent, grandparent, child, sibling, niece, nephew, or grandchild.

Notes

Anything else you need us to know