Memorial Plaque Order Form
Date | ||
English Name of Deceased (First, Last) | ||
Hebrew Name (English transliteration) (son of) (Ex: MOSHE BEN AVRAHAM (HA KOHEN or HA LEVI, blank for Yisrael) | ||
| Kohen , Levi , Israel | ||
Father's Hebrew Name (English transliteration) | ||
English Date of Death | Before or after Sundown | Hebrew Date of Death |
Name of person ordering plaque | ||
relationship to deceased | ||
Address | ||
City | State | Zip Code |
Home Phone (xxx-xxx-xxxx) | Business Phone (xxx-xxx-xxxx) | |
| The cost of a Memorial Plaque is $360.00 Plaques will not be ordered until paid for in full. Please allow at least 60 days for delivery. You will be notified upon placement of the plaque on the Memorial Wall. Printing Instructions:
Type in your information on screen, use your browser menu "File > Print" to print the form. | ||
|
Paid: Date: _____________________ Check No. ____________ Plaque Order Date: _____________________ Received Date: _____________________ Notification of family: _____________________ Wall Placement Date: _____________________ Plaque Location: _____________________ | ||
Young Israel of Northridge. 17511 Devonshire Street, Northridge, CA 91325
Legacy . .. Community . .. Family . ..
Legacy . .. Community . .. Family . ..