Memorial Order Form

This order form will automatically email your submitted information to the appropriate personnel at Everlasting Memories. After submitting the information, immediately attach the photo of the deceased to the email, and send it to us at this address:

Note: All fields are required, unless otherwise noted.


Name of Counselor: (your name)


Funeral Home or Cemetery Name:





Zip Code: 

Phone # : 
Fax # :  Not Required
Email : 

Your Background and Verse selections:





11" x 14"  
Information about the Deceased:  

Name of Deceased :

Name as it should appear on Memorial, if different than above : (not required)  

Sex of Deceased :

Date of Birth : ( xx/xx/xxxx )

Date of Death : ( xx/xx/xxxx )



Custom Verse : ( Extra charge of $10.00, limited to 650 characters, including spaces ) not required
Additional Comments : ( special requests, etc., not required )