Memorial Plaque Application Form

Memorial Plaque Application

Temple Beth Shalom
Purchaser's Name

First NameLast Name
Purchaser's Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Relationship to Deceased
Name to be Memorialized (English)

First NameLast Name
Hebrew Name in Full:
You can write out the English and we will transcribe OR you can upload picture of headstone or write out the Hebrew lettering and upload.
Upload headstone or Hebrew lettering here:

Cancelof
Check one:

KohenLeviIsraelite
Date of Death (English)
Date of Death (Hebrew if known)
Date of Death:

Before SundownAfter Sundown
THE $950 COST OF EACH MEMORIAL PLAQUE MUST BE PAID IN FULL WHEN ORDERED

MAKE CHECK PAYABLE TO: TEMPLE BETH SHALOM
NOTES:

1. The Hebrew name may be obtained from a marriage certificate or the monument/headstone itself.

2. Purchaser will be notified annually of yahrzeit observance.

3. In addition to the bronze yahrzeit plaque, those who are so memorialized will be inscribed in our Roll of Rememberance booklet which is distributed on Yom Kippur.
Date*

MonthDayYear
Date
Signature

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