Vigil Remembrance Offering Form

Sorrowful Mother
S H R I N E

4106 State Route 269
(mail to: P.O. Box 319)
Bellevue, Ohio 44811-0319
Phone: (419) 483-3435
Fax: (419) 483-6400

Vigil Light

Remembrance

Form

Thank you for considering a Vigil Light Remembrance. Your offering helps support the Sorrowful Mother Shrine.

You may print out and mail the Offering Form below along with your donation, or your may call the office to discuss it with one our staff members personally.

(PLEASE NOTE: the suggested offering is $2.00 for each Vigil Light Request.)

YOUR VIGIL LIGHT REQUEST IS: ______________________________________________________________________________

Name:_______________________________ Address: __________________________ City: ___________________ State: ______________ Zip: _________

Phone Number: ________________ Fax Number: _______________ E-Mail Address: ___________________________________________ Order Date: __________________