ORDER FORM

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You must complete this CLIENT INFORMATION FORM to be registered and confirm your email address.

RESPONSIBLE PARTY::::::::::::::::::::::::
Name:

Phone:

Email:

Address:

City:

State:

Zip Code:

SERVICE FOR:
MaleFemale
First Name:

Middle Name:

Last Name: (add Sr, Jr. III after last name if applicable):

Date of Birth:
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Date of Departure:
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FUNERAL SERVICE INFORMATION (Location):
Date:
//
Time:

Location Name:

Address:

City:

State:

Zip Code:

INTERMENT INFORMATION (Burial Location):
Location Name:

Address:

City:

State:

Zip Code:

VIEWING INFORMATION:
Location Name:

Location:

Date:
//
Time:

Funeral Director:

DELIVERY INFORMATION:
Address:

City:

State:

Zip Code:

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Call: (832) 856-1050

LMOY.ORG Contact Form