4” x 8” x 2” Missouri Red Brick
Lincoln Legacy Bandstand Walkway
on Mt. Pulaski Courthouse Lawn

 

3 lines of print – 13 characters per line       $35 / brick

 

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Line #1:

 

 

 

 

 

 

 

 

 

 

 

 

 

Line #2:

 

 

 

 

 

 

 

 

 

 

 

 

 

Line #3:

 

 

 

 

 

 

 

 

 

 

 

 

 

                                                     Please Print Clearly!

 

   Person Paying for the Memorial Paver:

     Name:_____________________________________________________________________________

     Tele:   (          )_________________________________  cell:  (         )____________________________

 

    Checks payable to:  Mt. Pulaski Bi-Centennial Committee

    (money is due when order is placed)

  
      for office use only

     Check #:  _______
    
     Received by:

 


     
Give to:  Mt. Pulaski Township Historical Museum (open noon to 4 pm – Tues – Sat)
                or  Salt Creek Attic - or  Mt. Pulaski Public Library

[Extra forms available at the above sites]