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


Order Form -

Product Code -

Price -

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
Quantity  
Color
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
Inscription:
Shipping Instructions:
Shipping Options:
Deadline for deliver
Date(DD/MM/YY)
Time
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:
Title(Mr.,Mrs.,Ms.)
First Name
Last Name
Email (ex:[email protected])
Address
City
State  Zip Code  
County
Phone
Alt Phone
Fax
Country
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:
Name
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.
Casketgallery.com


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
City
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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I have read and I agree to the Terms and Conditions of Sale



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