TO :	CasketGallery - Casket Ordered Form           Fax Number: 619-265-3455
FROM :
RE :	CasketGallery Faxed Order

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Order Form -

Product Code -

Price -

The price quoted excludes applicable sales tax, & shipping charges.

Please Specify: Color ________________________ Quantity   ________________________ Comments: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Shipping Address: Name ______________________________________________________________ Address ______________________________________________________________ City, State, Zip: ______________________________________________________________ Is this address a mortuary or funeral home? Yes/No Receiving Funeral Information: (If available) Contact Name ______________________________________________________________ Phone ______________________________________________________________ Fax ______________________________________________________________ Desired date and time of the funeral viewing/services: (It is not required to order the casket) Date ___________________________________________________(DD/MM/YY) Time ___________________________________________________ Buyer Information: Title _____ First Name __________________________ Last Name __________________________ Email __________________________ Address __________________________ City __________________________ State _____ Zip __________ Country __________________________ Phone __________________________ Alt Phone __________________________ Fax __________________________ County __________________________ Shipping Options   Please select one: Ovenight delivery 2 day rush delivery 3 day rush delivery Overnight Saturday delivery Standard delivery Deceased Person Information: First Name __________________________ Last Name __________________________ Height ___________ Weight ___________ Please call our toll free number (888)782-2753 to CONFIRM your order. Thank you. Casketgallery.com Method of Payment  Bill this order to: Name as it appears on the card: __________________________ Billing Address ______________________________________________________ Address line 2 ______________________________________________________ City _________________________ State/Province _____ Zip Code __________ Card Number _________________________ Card Type       Please select one: Visa Master Card Discover Card American Express Expiration Date        _______________ (DD/MM/YY) CVV2 _______________ What is CVV2?(Click Here) Select: Please select one: I have entered my CVV2 above My card has no CVV2 imprint My cards' CVV2 is illegible I have read and I agree to the Terms and Conditions of Sale (Please click here)