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Yartzeit Memorial Board

Donor Details
Full Name*
First NameLast Name
Phone Number*
Area CodePhone Number
E-mail*

Address*

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

Plaque Details
Full name of loved one*
Please make sure it is spelled correctly
Hebrew name of loved one
Father's Hebrew name of loved one
Date of passing*
MonthDayYear
Time of passing*
HourMinutes
Hebrew date of passing (if known)
We can calculate it if unknown
Payment
1 Plaque at $1000*Please complete one form per plaque
$1000

Payment*

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