1
Transaction
2
Contact information
3
Payment
FR
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In Memoriam Donation
Transaction
Amount of donation
$100
100$
$50
50$
$25
25$
Subtotal:
Total:
$
Palliative Care
Subtotal:
Total:
$
Oncology
Subtotal:
Total:
$
Total:
$
Information of the deceased
Name of the deceased
Date of death
Information of person to advise
Would you like to advise family?
Yes
No
Next
Organization's registration number:
14087 7101 RR0001
Time remaining in your session:
10
Time remaining in your session:
10