Cong.FREE KADDISH SERVICE Printout Fax or Mail Form

Cong. F.R.E.E. KADDISH & YAHRTZEIT SERVICES
FAX OR MAIL FORM
* Blanks marked with an asterisk are required

KADDISH IS BEING ORDERED BY:

Your name*: ________________________

Contact phone: ______________________

KADDISH IS TO BE SAID FOR:

Full name: _______________________

Full Hebrew name*:_________________

Father's name: ____________________

Fathers Hebrew name*:______________

Date of death (mm/dd/yy)*: __________

Hebrew date of death: _______________

Approximate time* __________________

Relationship to you: _________________

SEND CONFIRMATION LETTER AND YAHRTZEIT REMINDERS TO:

Name: _____________________________

Address: ___________________________

City / State: ________________________

Zip: _______________________________

KADDISH PLAN REQUESTED*: Annual Yahrtziet $180 Daily $360
Daily + Annual $500 Single Yahrtziet $36

I WISH TO PAY WITH*:

Visa
Master Card
American Express

Fill out card information box and mail or fax this form to (718) 467-2146

Check or money order

Mail in this form with check payable to:

Cong. F.R.E.E
1383 President St.
Brooklyn NY 11213

CARD INFORMATION:

Name of Card*: ____________________

Billing Address*: ___________________

Address 2: ________________________

City / State*: _____________________

Zip*: ____________________________

Card Number*:____________________

Expiration (mm/yy)*:_______________

Thank You

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