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English Name: _______________________________________________________________

Relation to you?____________________________________________________

Hebrew Name: ____________________________________________________Bat/Ben

Father’s Hebrew Name: _______________________________________________________

Date of Death: English _____________________Hebrew_____________________________

Cemetery: _______________________________ City: ____________________State: _____

Former Member? (Date)____________Memorial Plaque Located at:__________________

Would you like to purchase a Memorial Plaque for $500.00?      Yes No

Would you like to reserve a Memorial Plaque for $100.00?         Yes No

English Name: _______________________________________________________________

Relation to you?____________________________________________________

Hebrew Name: ______________________________________________________Bat/Ben

Father’s Hebrew Name: _______________________________________________________

Date of Death: English _____________________Hebrew_____________________________

Cemetery: _______________________________ City: ____________________State: _____

Former Member? (Date)____________Memorial Plaque Located at:__________________

Would you like to purchase a Memorial Plaque for $500.00?      Yes No

Would you like to reserve a Memorial Plaque for $100.00?         Yes No

Synagogue Membership for 2011-2012 includes:

Choice of Preferred High Holyday Synagogue Seat in the Main Sanctuary

Discounted use of Synagogue for Bar/Bat Mitzvot, Weddings and Simchot

Discounts when there are charges for Synagogue Events

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