| This gift is: |
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In Honor
of: |
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In Memory
of: |
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| Please notify: |
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Name:
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Zip:
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| Your Personal
Info: |
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Name:
Address:
City:
State:
Zip:
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Date:
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| Enclosed
is my gift of: |
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$
(Please make checks payable to:
Stony Brook Foundation NICU Development Acct.)
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| Please charge
my donation of: |
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$
to Mastercard or Visa (Circle one)
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