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At Chabad Jewish Center of Laguna Beach

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Memorial Plaque

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.)
Full Name

First Name Last Name
Hebrew Name
Date of Passing

Month Day Year
at Hour Minutes
Father's First Name (English)
Father's First Name (Hebrew)
Mothers First Name (English)
Mothers First Name (Hebrew)
2. Your Information
Full Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail
I would like to receive news and updates by email
Phone Number
Your Relationship to the Deceased
3. Yartzeit Information
(If there are any additional relatives to be notified before Yahrtzeit, please list name and address info.)
1. Full Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail
2. Full Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail
3. Full Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

4. Payment
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 receipt for income tax purposes will be issued.
Amount

I would like to be charged the full $500I would like to be billed $125 for the next four months.
Total

$0.00

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

Should be Empty:

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