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PLC:

a0078l

Agency:

gratiot county administration

For:

cremation permits

Phone:

989-875-5263

Address:

214 east center street
ithaca, michigan 48847

*Required Field

Payment Information

*Deceased Name:

*Date of Death:

(Month / Day / Year)

*Funeral Home Name:

*Funeral Home Phone Number:

(### - ### - ####)

*Funeral Home Email Address:

*Funeral Home Fax Number:

(### - ### - ####)

Notes:

Payment Amount

Payment Amount :

Subtotal:

$0.00

Total:

$0.00

Billing Information

*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: