Urn Payment Form

A word on security and privacy At Rose Floral we take all major credit cards. This information is encrypted and goes straight to Richard Rose at Rose Floral via e-mail and is not stored on any computer or server. Also, no customer information is dispensed in any way to any organization, all information you give us is strictly confidential.

Your Name

Account #

Address Line 1

Address Line 2

City

State

ZIP Code

Maintenance Service (watering. This service is only available at Fairview, Salem, Hazelwood, and St. Michael cemeteries)

Please include a bouquet of flowers for Memorial Day.

Daytime Phone

E-mail Address

Credit Card

Expiration Date

Card Number

Card Security Code (CVV/CID)

Comments (optional)