P A T R I C K   K E L L Y

C u s t o m   B i r t h   R e c o r d
(Comes with matt and frame)

To order, fill in the following form and send check or money order 
in the amount of $49.99 + $8.00 for shipping and handling to:

Patrick Kelly Studio
Suite 200
2310 Superior Avenue
Cleveland, Ohio 44114

E-mail: kellyhammstudio@aol.com


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Father's full name:

 _____________________________________________

Mother's name:

 _____________________________________________

Mother's maiden name:

 _____________________________________________

Baby's full name:

 _____________________________________________

Baby's date of birth:

 _____________________________________________

Country of birth:

 ___________ State: ___________ City: ____________

County:

 _____________________________________________

Mailing Address:

 _____________________________________________
_____________________________________________

Choice of matt color:

 Red ______ Blue ______ Green ______

Choice of frame color:

 Gold ___________ Silver ___________