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Memorial Plaque Order Form

Memorial Plaque Order Form

 

Yahrtzeit Memorial Plaque Order Form

 

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Sample Memorial Plaque Information:  
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Capture.JPG 
(sample engraved bronze memorial plaque) 

Below is a sample of the information required for each name submitted: 
Name : Walter Cohen  Hebrew Name:  Moshe  Father's Hebrew Name: Avrohom 
Date of Passing: September 1, 1989    Hebrew Date of Passing (if Known): 13 of Elul 5759 
Calculate the Hebrew date of passing here

 

Part 1: 
DEDICATION PLAQUE (Information of the person(s) whose memory you wish to honor)
I/we would like to dedicate 
  plaque/s.

This information will used to make the plaque; please complete exactly the way you would like it to appear.
PLAQUE #1   PLAQUE #2
Name   Name
Hebrew Name   Hebrew Name
Father's Hebrew Name   Father's Hebrew Name
Date of Passing
mm/dd/yyyy
  Date of Passing  
mm/dd/yyyy
Hebrew Date of Passing (if known)   Hebrew Date of Passing (if known)
 
Part 2: 
RELATIVE INFORMATION (individual requesting plaque)
First name    Last name
Address   City
State   Zip
Phone   Email
 
Part 3: 
PAYMENT DETAILS

The initial cost for inscription on a bronze plaque is $360. Each year thereafter, a contribution of $36 will be debited on the Yahrtzeit day.
A receipt for income tax purposes will be issued.

Name on card   Amount to be charged
Card Number   Card Type
Exp. Month       Exp. Year
Billing Zip      CVV Code    4 digits on the front of Amex. 
3 digits on back of Visa and MasterCard.
 

 

Press "Continue" below to continue to PayPal to make a payment.

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