1 March 2016
Repeat Customers: Please check
changed address? **_____  changed email address? **______

old address: ____________________________________________
Orange County New York Miscellaneous Orders and Decrees

Name (PLEASE PRINT):** _____________________________________________________

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 onsite in any way):

Name of Person:     Type of Record:  State, County # Vol, Page #
Example: DOE, JOHN  Estate              XX-50-35-80

List each ane every occurance of SAME estate or guardianship record. Pay as if you
are paying for one record.

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

4. _________________________________________________________________________

Add each line as needed. The order will be carefull checked out to ensure it is
same estate.

Cost:
Check One
USD $5.00  ___if by PayPal/Credit or Debit Card
USD $7.00  ___if by check

Please do NOT staple or tape check to the order. Please do not combine with
any other type of record.

CHECK MADE OUT TO:
SAMPUBCO

Mail to:
W DAVID SAMUELSEN
629 S HARMONY CT
Salt Lake City, UT 84102-3446

STOP! Please check and verify the accuracy of the information. Do NOT forget
to list "County of Record", which is listed at top of the index page the
indexed information is found on.