The Dempsey Burdick Memorial Foundation

Dear Family,

Your baby has been chosen to receive a special headstone as a gift from the Dempsey Burdick Memorial Foundation. You have the option of three choices of granite for the headstone, along with your personalized inscription. Additionally, you can customize your baby’s monument with an image from the samples below. Please print, complete, and e-mail to: support@dempseyburdick.com

NAME: _______________________________________
ADDRESS: ____________________________________
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PHONE: ______________________________________
E-MAIL: ______________________________________

Please circle your choice of stone.

	Georgia Gray, 10″ X 20″ X 4″
	Morning Rose, 10″ X 20″ X 4″
	Mahogany, 10″ X 20″ X 4″

Please print your inscription (include baby’s name and dates).
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Please select your artwork from the list provided below (circle one).
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Use the rest of this page to give us any notes.