Memorial Plaque Application Form

Part 1: Information of deceased (This information is inscribed on the Plaque. Please complete the form exactly as you would like the name to appear on the Plaque.)

First Name: (English)(Hebrew)

Last Name:Date of Passing:A.MP.M

Father's First Name: (English)(Hebrew)

Mother's First Name: (English)(Hebrew)

Part 2: Your information

Last Name:     First Name:     


City:   State:  Zip:

Your Email Address:  Tel. #

Your Relationship to the Deceased:

Part 3: Yartzeit Information (If there are any additional relatives to be notified before Yahrtzeit, please list name and address info.)

(1) First and Last Name:

Address:  Email:

(2) First and Last Name:

Address:  Email:

(3) First and Last Name:

Address:  Email:

Part 4: Payment Information                         

The act of Tzedakah (charity) in memory of a loved one helps strengthen the spiritual bond you have with them, and elevates the soul of the departed.

Suggested contribution for a Memorial Plaque is $500. A reciept for income tax purposes will be issued.

 Please charge the entire amount to my credit card.

 I would like to be billed $125 for the next four months.

Name on card:  AmexMasterCardVisa

Credit Card #  Expiration Date