NESHAMA (SOUL) MEMORIAL LAMP

PLAQUE FORM

 

for J.L.E. Lake Success Chabad

 

First Name of Deceased

 *

Family Name of Deceased

 * 

Hebrew Name of Deceased

 *

Father's Hebrew Name of Deceased

 *

DD/MM/YY of Passing

 *

Time of Passing

Daytime  Dusk Evening

Relationship of the Deceased 

Mother Father Brother 
Sister Spouse Other

Other: (If Applicable)

Your First Name

 *

Address

 *

City/State/Zip

 *

Phone Number:

 *

Email:

 *

Amount:

$770 per plaque.

 Please fill one form per plaque requested. 

Card Number:

 Type: 

 * 

 *

Expiration Date:

 *