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: * This page uses 128 bit SSL encryption to keep your data secure.