Memorial Plaque Order Form

 

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Kehillat Chovevei Tzion
P.O. Box 544
East Setauket, NY 11733

Memorial Plaque Order Form

Hebrew Name

.

English Name

.

English Date

.

Hebrew Date

.

Donor(s)__________________________ Telephone____________________

Relationship to donor(s)___________________________________________

Please print this page, fill it out, and send it along with a check for $180 to the P.O. Box.