Memorial Garden Paving Stone
Order Form
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Please complete all information and mail this form with payment in full to (checks should
be payable to Our Lady of the Chesapeake):
Our Lady of the Chesapeake
8325 Ventnor Road
Pasadena, MD 21122
Please complete a separate order form for each paving stone that you are sponsoring.
Please be aware that it may take up to several months for the stone to actually be placed
in the Memorial Garden.
Name: _________________________________________
Date: ________________
Street Address:
______________________________________________________________
City, State, Zip: _________________________________________________________
Telephone: ________________________________
Amount Enclosed ($50 per paving stone) $___________________
Inscription -- Please Print (14 characters each line, including spaces and punctuation)
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___This is a Gift. Please send an acknowledgement certificate to:
Name: _______________________________________________________________
Address: ______________________________________________________________