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If this is a gift in memory of or in honor of someone, please complete the Memorial and Honorary Gifts section at the bottom of this form.

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$ 250.00

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Fundraising activities on behalf of Mary Hitchcock Memorial Hospital (MHMH) is conducted by Dartmouth-Hitchcock Health, a 501(c)(3) recognized charity by the IRS (EIN#26-4812335), for the benefit of MHMH. Your gift will appear on your credit card statement as a payment to "D-HHealth Donation".

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