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Repeat Customers: Please notify if changed address and/or changed email address

                              SAMPUBCO ORDER FORM
                      Letters of Administrations

Name:___________________________________________________________________________

Email (REQUIRED!):______________________________________________________________

Street/P.O. Box:________________________________________________________________

City/State/ZipCode+4:___________________________________________________________
(out of USA - City, Province, Country, Postal Code)

Order (do NOT alter the information as listed in any way):

Name of Person:     Residence:  County of Record:  State, County # Vol, Page #
Example: DOE, JOHN  Anyplace    Anycounty          XX-50-35-80

Example: DOE, JOHN - Rushford - Allegany - NY-1-35-80

1.______________________________________________________________________________

2.______________________________________________________________________________

3.______________________________________________________________________________

4.______________________________________________________________________________

5.______________________________________________________________________________

Scanned Copy - send by Email

Cost:
$3.00 if paid through PayPal/Credit Card
$4.00 if paid by check
Paper Copy - send by mail
$5.00 if paid through PayPal/Credit Card
$6.00 if paid by check

Number of records: _______ X USD $_____ = ______________ check / PayPal /eCheck

Do NOT staple or tape check to the order. DO NOT COMBINE WITH NATURALIZATIONS, WILLS,
LETTERS OF TESTAMENTARY, SURROGATE'S RECORDS OR GUARDIANSHIPS!

Check Payable to SAMPUBCO

Mail to:
W. David Samuelsen
P.O. Box 11874
Salt Lake City, UT 84147-0874

STOP! HAVE YOU CHECKED FOR ACCURACY IN INFORMATION YOU FILLED IN?
HAVE YOU REMEMBERED TO LIST COUNTY/STATE IN REQUIRED SPACE?