Military Urn Order Form

* Required

Order # * If you don't have one, put in "123" (no quotes)

Title

First Name *

Last Name *

Address *

City *

State *

Zipcode/Postcode *

Country *

Phone Number *

Fax Number

Email Address *

Today's Date

Date Needed

Deceased Personal Information

Full Name

Date of Birth

Date of Passing

Branch of Service

Retired?

Dates of Service - Active Duty

Dates of Service - Reserves

Urn Wood Choice

Top of Urn

Medallion

Branch Symbols Option

Front Panel Options

Framed Photo

Personal Information Incorporated?

If original photos are given, can they be used or do they require them back?

Ribbon Medal

Left Panel Standard

Highest Rank

Right Panel Options

Branch of Service Plate

Eagle Plate with U.S. Insignias

Ribbon Rack

Up to 4 mini medals

Back Panel Options

Additional Notes:

Additional Options

Military Frame (Photo, Info, Small Medallion) 8x10 @ $100.00

Keepsake Urn @ $140.00

Interior Flocking/Container Color Change Option (Branch Color Standard)

Notes: Digital photos should be of the highest uncompressed resolution possible.