Plattsburgh Barracks Veterans Park Memorial Bricks

Top: Your Name, Address & Phone Number
Lines 1, 2 , 3 is what you want inscribed on the brick. 
13 characters including spaces maximum.


Name:____________________________________________
                                                                         
Address:__________________________________________    
                                                                         
Phone #:__________________________________________


Line 1:____________________________________________

Line 2:____________________________________________

Line 3:____________________________________________


Amount Donated: $50.00
Make Check payable to: DAV Chapter 179
Mail top section and check to:                         
Paul E. Dumas                                                 
271 Irish Settlement Rd                                    
Plattsburgh, NY 12901-5949                             
_________________________________________________________________________________
Keep this Portion as your receipt:
Amount Donated $50.00
Name_____________________
Address___________________
Check#____________________