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Date __ __ __                                                                                                                                                  Initials ____ __ _


$__________ Memorial     $__________ Gift

Donation for _____Adams Memorial _____Auburntown _____Genealogy

In Memory of ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ _________

Name as it will appear on book plate.

Mailing Address __________________________________________________________

Address where notice of donation is to be sent.



Name of Donor (s) ____________________________________________________________

Name (s) as they will be recorded on book plaque.

Address & telephone ____________________________________________________________

Number of donor (s)




Title selection will be at the discretion of the Director following the collection development plan.

A bookplate will be placed in the purchased book stating the name of both the honored and donor.A card will be sent as notification to either the funeral home or person designated by the donor(s).  Except in rare instances, we do not accept pre-purchased books by the donor for memorial gifts.  This form constitutes the entire understanding of the agreement

May we mention your gift in press releases? Yes _____ No _____

Memorial Card Sent _______Thank You Sent ___________

Items (s) Purchased: