Memorial Plaque Information

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Fill out the form below with the information for your memorial plaque

NOTE: If you have not yet gone through Paypal, please go do so above after clicking Submit. Your purchase will not be complete until both this form AND the Paypal purchase have been completed.

Email *

Purchaser Information

Your Name *

Phone Number *

Information for the Plaque

Name of the Deceased *

English Date of Death *

Column 1

Row 1

Hebrew Date of Death

YYYY

IMPORTANT: If you haven't donated for your purchase yet, please the Paypal cart above after you have submitted this form.

A copy of your responses will be emailed to the address you provided.

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