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PLC:

a004v1

Agency:

antrim county treasurers office

For:

cremation permits

Phone:

231-533-6720

Address:

203 east cayuga
bellaire, michigan 49615

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*Deceased Name:

Middle:

*Last:

*Date of Death:

(Month / Day / Year)

*Funeral Home Name:

*Funeral Home Email:

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*Payment Type:

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Subtotal:

$0.00

Total:

$0.00

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*First Name:

Middle Initial:

*Last Name:

*Billing Address:

*City:

*State/Province:

*Zip:

*Country:

*Phone Number:

*Credit/Debit Card:

(enter the full card number without any dashes or spaces)

*Expiration Date:

*Card Security Number:

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