TO : CASKETGALLERY.COM (Fax # 619-265-3455)
RE : Faxed Order

Order Form - Bronze - Companion

Product Code - OGBRZ5

Price - $899.00

The price quoted some colors may incur extra cost, please call to confirm your pricing 1-888-78-CASKET (1-888-782-2753) to CONFIRM your order from Casketgallery.

Price excludes applicable state sale tax, shipping, and Cemetery Installation charges.

Please Specify:
Product Number
Product Design
Size Description
Item# or Description
Font Options Others
Background Texture: Others
Pick Emblems (If Desired) and indicate placement in Special Instructions:
Category for Design Number
Emblem 1
Emblem 2
Emblem 3
Shipping Instructions:
Shipping Options:
Deadline for deliver
Please fill in these boxes below:
Deceased Person Information:
First Name :Second Name (If you need for a double one - Optional):
First NameFirst Name
Middle NameMiddle Name
Last NameLast Name
Date of Birth Date of Birth
Date of Death
Date of Death
*Note: If all that is needed is one date just fill in the date of birth field.
Special Request (From Phone):
Buyer Information:
First Name
Last Name
Email (
State  Zip Code  
Alt Phone
Relationship to the deceased.
Shipping Options  
Shipping Options   Please select one  (Overnight delivery,2 day rush delivery,3 day rush delivery,Overnight Saturday delivery, Standard delivery)
Cemetery/Shipping Address:
City, State, Zip:
Is this address a Cemetery/Funeral Home?         (No,Yes)    

Please call our toll free number
1-888-78-CASKET (1-888-782-2753) to CONFIRM your order.

Thank you.

Method of Payment  credit card

Bill this order to:

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Name as it appears on the card:
Billing Address (Must be the billing address of the credit card)
Address line 2
State/Province   Zip Code  
Card Number  
Card Type  (Visa,Master Card, American Express, Discover Card)
Expiration Date       (Month/Year)
CVV2       What is CVV2?(Click Here)
Select: Please select one:
I have entered my CVV2 above
My card has no CVV2 imprint
My card's CVV2 is illegible

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