Gifts in Memory or In Honor

A donation in memory or in honor of a loved one can be a special way to celebrate the life of your loved one, to honor someone living or to commemorate a special occasion.

Download Fax / Mail-In Form

Gift in Memory or in Honor

Name*
Please enter your first and last name.
First Last
Donation Amount*
Enter the amount you'd like to donate.
Anonymous Donation
Check this box if you'd like your your donation to be anonymous.
- I wish to donate anonymously
In Memory Of
The name of the person you'd like this donation to be made in the memory of.
In Honor of
The name of the person you'd like this donation to be made in honor of.
In the Occasion of
The name of the occasion to which you'd like this donation to be made.
Use of Donation
Please select what you would like this donation to be used for.
Paper Receipt
I would like a paper copy of my donation receipt sent to me in the mail.
- Yes
- No
Digital Copy of Receipt
I would like a digital copy of my donation receipt sent to me in the mail.
- Yes
- No
Digital Receipt Email Address*
Please enter the email address you'd like your digital receipt to be sent to.
Latest News
Please contact me with the latest Stein Hospice News and Events Information.
- Yes
- No
Additional Donors
Please list the names and addresses of additional donors (if applicable).
Send a Notification to a Friend or Family Member
I would like you to send a notification of my donation to a friend or family member.
- Yes
- No
Friend / Family Member Name*
Please enter the first and last name of the friend or family member you would like us to send a notification of this donation to.
First Last
Friend / Family Address*
Please enter the mailing address of the friend or family member you would like us to send a notification of this donation to.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Friend / Family Phone*
Please enter the phone number of the friend or family member you would like us to send a notification of this donation to.
Friend / Family Email
Please enter the email address of the friend or family member you would like us to send a notification of this donation to.
Billing Address*
Please enter your billing address.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Please enter your phone number.
Email*
Please enter your email address.
Credit Card*
Please select and input your payment method.

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Total
This is the total amount you will be donating today.
$0.00

Thank you.

We appreciate your support!
Contributions are tax-deductible to the extent permitted by law.
Stein Hospice is a not-for-profit 501(c)(3)organization