Have a Memorial Plaque installed on
CBST's Memorial Board inside our sanctuary

MEMORIAL PLAQUE ORDER FORM

(PLEASE USE A SEPARATE FORM FOR EACH PLAQUE REQUESTED)

I wish to have a memorial plaque installed for:

__________________________________________
Date of death: English calendar

_____________________________________________
Date of death: Hebrew calendar. If you do not know this date,
please indicate if death occured before or after sundown.

RELATIONSHIP

________ Member, for father, mother, brother, sister, son, daughter, spouse, lover, $100

________ Member for other persons: $200

________ Non-member: $300

________ Reservation (one per each plaque purchased) to be paid within 3 years, priced according to categories above for

_________________________________________________.

________ Additional reservations to be paid immediately, price according
to categories above for _________________________________.

TOTAL REMITTANCE $_______________________

Please make checks payable to Congregation Beth Simchat Torah and mail to:
Congregation Beth Simchat Torah/Memorial Board
57 Bethune Street
New York, New York 10014
Your name _______________________________________

Address __________________________________________

Phone (____) _________________

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