
Please join the staff and volunteers of Hand In Hand Hospice as we celebrate and remember the lives of special people in our community
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2. Name of Individual to Recognize (Please Print):
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3. Name of Individual to Recognize (Please Print):
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4. Name of Individual to Recognize (Please Print):
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Number of Butterflies: _______ at $10 each = $ _______ enclosed.
Donor’s Name(s):
___________________________________________________Phone_______________
Address _______________________________City________________________
State_____ Zip _______
Will you attend the Butterfly Release? Yes ____ No _____ Approx # attending ______
Please mail check with this form to:
Hand In Hand Hospice
1201 W. 12th Ave.
Emporia, KS 66801