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Application for Veteran's Brick Paver
Mt Zion Historical Park


Remembering our ancestors is a very important way to honor them and their contributions to the history of the Bennett's Valley. We would appreciate a picture of the veteran in uniform if you have one, so this can be added to the vet list.

Note: Items designated with a * are information to be maintained in the Mt. Zion Historical Societyís genealogical records only.




NAME OF VETERAN (On paver):__________________________________________________

Veteran's RANK (to be on paver):________________________

WAR IN WHICH SERVED:___________________________________________

         NOTE: (If a veteran's term of enlistment covered any part of a war or conflict, they are considered as a veteran of that war. If not, they are considered a peacetime veteran.)

Served with(circle): ARMY- NAVY- AIR FORCE- MARINE- COAST GUARD- MERCHANT MARINES **

VETERAN'S UNIT (If Known):_______________________________**



PLEASE CIRCLE IF APPLICABLE:       KIA    MIA    POW

         (Note: Pavers for Veteranís who fall into one of these categories are purchased jointly by Post 978 of the American Legion and the Mt. Zion Historical Society)

VETERAN'S BIRTH DATE_______________DEATH DATE (If applicable)______________

CEMETERY, City, State:________________________________________________________**


PLEASE LIST ADDITIONAL INFORMATION YOU CONSIDER RELEVENT:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________


PERSON PURCHASING PAVER______________________________________PHONE NO.___________________

ADDRESS______________________________________________________________________

E-MAIL ______________________________________________________
(Your email will be only used to send you our newsletter or other special Society information- we will not give out to anyone else.)

COST OF EACH VETERAN PAVER IS $60.00

COPY AND FILL OUT APPLICATION AND MAIL WITH PAYMENT OF $60 TO:
(Make check payable to Mt Zion Historical Society)


MT ZION HISTORICAL SOCIETY
%SUSAN McCLINTICK
McCLINTICK ROAD
WEEDVILLE, PA 15868

PHONE: 814-787-7675

Do you wish a notification of this purchase sent to the veteranís family? Yes_____ No_____


If yes, Name___________________________________ Address______________________________________

City_____________________________________ State & Zip_______________________________

 

 

 




 

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