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Sanctuary Memorial Lights Plaque Request Form
Please verify reCaptcha before submitting the form.
As long as we live, they too will live,
For they are now a part of us
As we remember them.
*
Yes, I would like to purchase a Sanctuary Memorial Lights Plaque.
Yes, I would like to purchase a Sanctuary Memorial Lights Plaque.
The cost of the Sanctuary Memorial Lights Plaque is $250. Payment in full is required for your order to be processed.
A copy of the plaque proof PDF will be provided for your review and approval before the order is placed with the manufacturer. It takes about 6 weeks for plaques to be completed and mailed to the synagogue.
Please fill out this form once per order. You may submit this form as many times as you wish.
Information About the Departed
English Name of Departed (as you want it engraved on the plaque)
Hebrew Name of Departed (Hebrew characters)
Hebrew Name of Departed (English characters)
Father's Hebrew Name (Hebrew characters)
Father's Hebrew Name (English characters)
Mother's Hebrew Name (Hebrew characters)
Mother's Hebrew Name (English characters)
Date of Death
Check here if after sunset
Check here if after sunset
Purchaser Information
Purchaser's Name
Relationship to Departed
Address
City
State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Telephone
Email
Date of Request
Wed, November 13 2024 12 Cheshvan 5785