Chabad Kevura Burial Form

Officiating Rabbi: Rabbi Shmuel Marcus

State of California Chabad Rabbis fee: $1000
Name of deceased:

First Name Last Name
Hebrew name and father’s name of Deceased:
Date and time of passing:

Month Day Year
at Hour Minutes
Location of service:
Graveside or chapel:
Spouse:

First Name Last Name
Children:

Separate with comma
Brothers:

Separate with comma
Sisters:

Separate with comma
Grandchildren:

Separate with comma
Pallbearers:

Separate with comma
Psalms:
Eulogy:
Eshet Chayil (For women only):
Mourners performing Kriah:
Mourners Reciting Kaddish:
Shiva Information:
Payment amount:*

$1000
I would Like to donate an additional amount of:

$
Total:

$0.00

Payment:

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

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