Gift Form

Shirley Historical Society

182 Center Road, P.0. Box 217, Shirley, MA  01464-0217

 

Item Name ____________________________________________

 

Donor Name _________________________________     Date Received ____________

 

Donor Address __________________________________________________________

 

          Email __________________________________    Phone ___________________

 

Book _____           Paper _____           Photo ______        File _____ Object _______

 

Object History

Original Owner’s Name and Information ________________________________

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Use of Object ______________________________________________________

 

Date of Use ____________________            Place of Use ___________________

 

Other background information ______________________________________________

 

          _________________________________________________________________

 

          _________________________________________________________________

 

_________________________________________________________________

 

          _________________________________________________________________

 

          _________________________________________________________________

 

 

The Shirley Historical Society has my permission to use this object as they see fit.

 

          Signed ___________________________________________________________

 

Received by _____________________________              Date ____________________