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:

  *