Brick Order Fillable Form
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Office Use Only Order #
                                                                                        Received:           Ck#
                                                                                       Amount:
                                  Brick Order Form
                                                  The Town of Clay Memorial Park
                                             4401 State Route 31 Clay NY 13031
                                                      (315) 652-3800 ext. 179
The Town of Clay is proud to support a Memorial Park at its main office. This area is for anyone interested in taking a
walk through a serene atmosphere while reflecting on loved ones who have passed, as well as honoring the victims
who tragically lost their lives on September 11, 2001 (911). We invite you to take a "Walk of Memories" in a calming
environment.
Interested in purchasing an engraved brick? Engraved bricks may be purchased for *$50.00 each by completing the
information at the bottom and on the reverse side of this form. Your loved one can become a permanent part of the
Town of Clay Memorial Park.
*amount based on vendor and market fluctuations

Example                             Example 2                     Example 3
                        John Doe                             Jane Doe                      Jane Doe
                                                             Teacher                       Murphy
                                                                                          1925-1993
        Purchased by:                                                      Phone:
        Address:
        Brick Purchase: $            . Please enclose a check or money order made payable to the Town of Clay (We do not
        accept cash as a method of payment). All engraved brick requests are at the approval of the Clay Town Board.
        Bricks are not engraved during winter months. You will be called when your brick is ready.
        Name to contact when Brick is ready:
        Signature:

PLEASE TYPE OR PRINT CLEARLY
             Brick Size – 8” x 4” x 2 ¼” ●     Up to 3 lines per brick
             13 spaces each including letters spaces and punctuation
                                      Brick 1
              Fill out exactly as you wish it to appear on your brick
                                      Brick 2
              Fill out exactly as you wish it to appear on your brick
                                      Brick 3
              Fill out exactly as you wish it to appear on your brick