In Loving Memory

Directions:

Click the "Printer Friendly" button at the bottom of the page before you type in your information.

Please print your completed form and mail it along with your contribution.

Make checks payable to:

Wells Nursing Home, 201 West Madison Avenue, Johnstown, NY 12095

Attention; Memorial Contributions

I would like to make a memorial contribution:

In Remembrance of:

In the Amount of:

Deposit My Gift into the:

Activity Fund

Resident Council Fund

Rehabilitation Department

Nursing Department

General Disbursement Fund

Comments:

Donor Information:

Donor(s) Name:

Address:

City:

State:

Zip:

Please send a card of remembrance to:

Name:

Address:

City:

State:

Zip: