VCK Service Request & Intake Form
Name of Requestor
*
First Name
Last Name
Phone Number of Requestor
*
Please enter a valid number you can be reached 24/7.
Email of Requestor
*
example@example.com
Synagogue / Organization Name of Requestor
*
Services Being Requested
*
Shmirah
Tahara
Education
Other
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Deceased Information
To properly prepare, we respectfully ask you answer the following questions to the best of your ability regarding the wishes of the deceased and their family.
English Name of the Deceased
First Name
Last Name
Hebrew name of the Deceased
Gender Identity of the Deceased
Male
Female
Other
If requesting Shmirah, does the family wish to participate?
Yes
No
Unknown
Contact Information for the Deceased’s Family Member (we will not contact until after requestor has given permission)
First Name
Last Name
Please enter a valid phone number.
If requesting Tahara, does the family have a tallit they prefer to include with the burial gaments?
Yes
No
Unknown
If requesting Tahara, please select any of the following that apply:
The deceased will be embalmed.
The deceased will be cremated.
The family will provide non-traditional burial garments for the deceased to be buried in.
If requesting Tahara, please describe any requests made by the deceased or their family which are not considered "traditional" which would impact how we perform our services.
If requesting Tahara, please indicate any special circumstances or conditions we should be aware of regarding the body of the deceased.
Excessive weight (over 250 lb)
Stature (over 6'1)
Significant trauma to the body (open wounds, burns, missing limbs, etc)
Autopsy performed
Tissue, organ, or skin donor
Other
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Scheduling
Please provide the following information to the best of your ability so we can gather a team to serve. Only fill out the portion for which you are requesting our services.
Date & Time Shmirah Begins (upon arrival at funeral home or other location)
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Shmirah
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date and Time of Tahara
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Tahara If NOT at the Same Location as the Shmirah OR if Shmirah is not requested
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date & Time of Burial Service
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
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