Printed fromChabadManhattanBeach.com

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Memorial Dedication Plaque

Plaque Dedication Form
1. Your Contact Info
Your Full Name*

First Name Last Name
Your Cell Phone*

Area Code Phone Number
Your E-mail*
2. In Loving Memory of

PLEASE FILL IN THE INFORMATION TO BE INSCRIBED ON THE PLAQUE

Use separate form for each Plaque
Loved one: Name*

First Name Last Name
Hebrew Name If you Know it
His/Her Father's Name

First Name Last Name
His/Her Father's Hebrew Name If you Know it
Father is a Kohen, Levi, Israelite or Do Not Know?
His/Her Mother's Name

First Name Last Name
His/Her Mother's Hebrew Name If you Know it
Are both Parents Jewish?*
Date of Passing* Check Death Certificate if Accessible

Month Day Year
Time of Passing*

Hour Minutes
Other Info
3. Payment Info
Plaque Type*

Standard Size Plaque - $540.00 Large Size Plaque - $1,250.00
Total

$0.00

Payment*

Credit Card Other

Postal / Zip Code

Country

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