Yahrzeit Plaque Order Form
In memory of
*
First Middle Last
Name of person ordering
*
The deceased is my ...
*
parent, grandparent, child, etc.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
Phone Number
*
Area code + phone number
Yahrzeit Plaque Inscription Information
Name (English)
*
Name (Hebrew)
in English transliteration
Date of Death (Gregorian)
*
Did death occur after sundown?
*
yes
no
I don't know
Date of Death (Hebrew)
Yahrzeit Plaque
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USD
$300.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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