To Make A Memorial Donation

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" rowspan="2" width=210 BGCOLOR="#99CC99" TEXT="#080000" bgproperties="fixed" background="1628dfc3.jpg"> <div> <B><IMG SRC="17fbea20.jpg" border=0 width="190" height="162" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <bR> <div> <B><IMG SRC="344be970.jpg" border=0 width="190" height="151" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> </td> <td valign="top" colspan=2 height=82 BGCOLOR="#CCCC99" TEXT="#080000" bgproperties="fixed" background="0428dfe1esnpes.jpg"> <div> <FONT SIZE="5" COLOR="#000000" FACE="Calligrapher" ><B>Mountain Hospice</B></FONT><B>  </B><B>     </B><A HREF="index.htm" TARGET="_top" TITLE="Mountain Hospice"><U><B>home</B></U></A></div> <div> <A HREF="id48.htm" TARGET="_top" TITLE="Awareness 1000"><U>"Awareness 1000"</U></A><FONT SIZE="1" COLOR="#000000" FACE="Times New Roman" >   |   </FONT><A HREF="id17.htm" TARGET="_top" TITLE="Contacting Mountain Hospice"><U>Contacting Mountain Hospice</U></A><FONT SIZE="1" COLOR="#000000" FACE="Times New Roman" >   |   </FONT><A HREF="id18.htm" TARGET="_top" TITLE="Questions about Hospice"><U>Questions about Hospice</U></A><FONT SIZE="1" COLOR="#000000" FACE="Times New Roman" >   |   </FONT><A HREF="id19.htm" TARGET="_top" TITLE="Services Provided"><U>Services Provided</U></A><FONT SIZE="1" COLOR="#000000" FACE="Times New Roman" >   |   </FONT><A HREF="id25.htm" TARGET="_top" TITLE="Volunteers"><U>Volunteers</U></A><FONT SIZE="1" COLOR="#000000" FACE="Times New Roman" >   |   </FONT><A HREF="id26.htm" TARGET="_top" TITLE="Grief Support"><U>Grief Support</U></A><FONT SIZE="1" COLOR="#000000" FACE="Times New Roman" >   |   </FONT><A HREF="id28.htm" TARGET="_top" TITLE="Medical Director"><U>Medical Director</U></A><FONT SIZE="1" COLOR="#000000" FACE="Times New Roman" >   |   </FONT><A HREF="id29.htm" TARGET="_top" TITLE="Board of Directors"><U>Board of Directors</U></A><FONT SIZE="1" COLOR="#000000" FACE="Times New Roman" >   |   </FONT><A HREF="id31.htm" TARGET="_top" TITLE="Notice of Privacy Practices"><U>Notice of Privacy Practices</U></A><FONT SIZE="1" COLOR="#000000" FACE="Times New Roman" >   |   </FONT><B>To Make A Memorial Donation</B><FONT SIZE="1" COLOR="#000000" FACE="Times New Roman" >   |   </FONT><A HREF="id32.htm" TARGET="_top" TITLE="Announcements / Upcoming Events"><U>Announcements / Upcoming Events</U></A><FONT SIZE="1" COLOR="#000000" FACE="Times New Roman" >   |   </FONT><A HREF="id44.htm" TARGET="_top" TITLE="Employment with Mountain Hospice"><U>Employment with Mountain Hospice</U></A></div> </td> </tr><tr> <td valign="top" height=398 colspan=2 BGCOLOR="#CCCC99" TEXT="#080000" bgproperties="fixed" background="0428dfc3.jpg"> <div> <I>To Make A Memorial Donation</I></div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> <I><IMG SRC="0a85ee20.jpg" border=0 width="350" height="226" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></I></div> <div> <I><B>"It's the Quality of Life That Makes a Difference."</B></I></div> <bR> <div> <I>     Our ability to meet all the patients needs of Barbour, Grant, Randolph, Tucker, Pendleton and Pocahontas Counties, are made possible by the continued dedicated financial support from our communities.</I></div> <div> <I>Your support enables MOUNTAIN HOSPICE to focus our attention on providing high quality hospice services.</I></div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <I>*****Print this page, to make a Donation*****</I></div> <bR> <div> <I>All Contributions are Tax Deductible</I></div> <bR> <div> <I>Enclosed is my donation of : $___________________________</I></div> <bR> <div> <I>[   ] </I><FONT SIZE="3" COLOR="#990000" FACE="Arial" ><I> </I></FONT><FONT SIZE="3" COLOR="#660033" FACE="Arial" ><I><B>In Memory of:</B></I></FONT><I>___________________________________</I></div> <bR> <div> <I>[   ]  </I><FONT SIZE="3" COLOR="#660033" FACE="Arial" ><I><B>In Honor of:</B></I></FONT><I>_____________________________________</I></div> <div> <I> </I></div> <div> <I>Donation made by:___________________________________</I></div> <div> <I>Address:___________________________________________</I></div> <div> <I>__________________________________________________</I></div> <div> <I>                                              </I></div> <div> <I>Please return this page with check made payable to:</I></div> <div> <I>     </I><FONT SIZE="5" COLOR="#000000" FACE="Arial" ><I> </I></FONT><FONT SIZE="5" COLOR="#660033" FACE="Calligrapher" >Mountain Hospice</FONT></div> <div> <I><B>          </B></I><I><B>1600 Crim Avenue</B></I></div> <div> <I><B>        Belington, WV  26250</B></I></div> <bR> </td> </tr></table></body>