Gravestone Photo Request Form

Your Name:
Email Address: [print or type very clearly]
Phone: [include area code]
City, State, Zip

Gravestone Photo Information for Ancestor

Full Name of Deceased:
Date Born:
Date Died:
Name of Cemetery . . if Known

If a second photo is desired in same cemetery, give same above details in the comment area below.

Additional Comments:

Amount Enclosed: $ 10.00
Optional Add'l Contribution for Cemetery Restoration: $ ________

Proceeds from this project go towards cemetery restoration projects, transcription expenses and other efforts
related to Van Buren County genealogy records preservation.

Please print and complete this form and mail with payment to:

Van Buren Co Genealogy Society
Photo Lookup Project
704 Franklin Street
Keosauqua, IA 52565

Gravestone Photo Request Form

Gravestone Photo Information for Ancestor

Amount Enclosed: $ 10.00 Optional Add'l Contribution for Cemetery Restoration: $ ________

Amount Enclosed: $ 10.00
Optional Add'l Contribution for Cemetery Restoration: $ ________