ORDER FORM
To Contact Us:
ROLAND PRODUCTIONS GRAVE CARE
PO Box 28
Stormville, NY 12582
(845) 475-6041
Website: rolandproductionsgravecare.net
Email: [email protected]
To Order:
Note: If ordering BY MAIL, please print the following form, fill it out, and mail it with your
check. Or simply write out the information requested below, and mail it with your check,
made out to ROLAND PRODUCTIONS, and mail to PO Box 28, Stormville, NY 12582.
Customer Name ________________________________________
Address _______________________________________________
City, State, Zip _________________________________________
Telephone _____________________________________________
Email address __________________________________________
I wish to order One Grave Visit For St. Patrick’s Day: $50
Cemetery / Town ________________________________________
Name(s) on Grave _______________________________________
Date(s) of Death, if known
(even the year is helpful) __________________________________
Grave Location, if known
(even the section is helpful) ________________________________
Choice of Decoration:
Bouquet of ______ Fresh Cut, Green and White Carnations, or
Bouquet of ______ Lifelike, Green and White Silk Carnations
______ Optional Decorative Green Shamrock Ornament
Pebble to be left on stone or marker?
______ Yes, ______ No
Before & After Photos to be sent by _______ Email, ______ Postal, to above address.
Note: Multiple graves being visited in the same cemetery at the same time will be eligible for a
discount based on the number of graves and the proximity to each other. Please call us for more
information.
___ I am interested in a 4-Visit Annual Care Package ($180). Please send me more information
(without obligation!)
___ I am interested in a 10-Visit Annual Care Package ($400). Please send me more information
(without obligation!)