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ALS Independence IN MEMORIAM PERMISSION FORM Name of Person in portrait: ____________________________________ Address of Person in Portrait: ___________________________________ City: _______________________________ Province: ______________________________ Postal Code: ____________________________ E-Mail:_________________________________ Lifespan of Person in Portrait (eg: 1941 – 2000):_________________________ Date of Diagnosis: ______________________________ By my own personal authority or as Power of Attorney I hereby authorize ALS Independence.com to add the above person to the IN MEMORIAM page on the www.alsindependence.com web site. Signature: __________________________________ Date: _________________________________ Please forward form and picture to: George Goodwin 20 Congress Cres. Apt. 401 Hamilton, Ont. L8K 5H7
Or by e mail to: george.goodwin@sympatico.ca
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