Contact Form

My Name (required)

My Email:

My relationship to the deceased:

First name of the Deceased:

Last name of the Deceased:

Hebrew name of the Deceased:

Hebrew name of the father of the Deceased
(If not available, the English name of the father. If not available, then the name of the mother.):

Family members who have survived the Deceased:

Name:

Relationship to Deceased:

Name:

Relationship to Deceased:

Date and time of passing:

Please specify:

Date of burial:

Location of passing:

Location of cementary (City,State):

Services:

 Kaddish Service- $540 Yahrzeit Service - $180 Extra Yahrzeit Kiddish - $90

Please indicate form of payment:

 Check will be mailed (see address below) Credit card (Secure Service) Paypal(please fill out and send the form and go to the bottom of the page to complete payment)

Please send your Check made out to Kaddish Jerusalem REGISTERED MAIL to:

Rabbi Shalom Gold
3 Gal-ed Street
Old City Jerusalem,
Israel 97500

Type of Card:

Name on the Card:

Credit Card Number:

Enter CVC number (Back of the card):

Expiration Date(MM/YY):

Billing Address:(person, street, apt.)

City:

State/Province:

Zip Code:

Country:

Tel Daytime:

Tel Evening:

Mobile:

Please send an annual yahrzeit reminder to the following individuals:

1.

Name:

Address:

City:

State/Province:

Zip Code:

Country:

Tel Day/Night:

Email:

Relationship to Deceased:

2.

Name:

Address:

City:

State/Province:

Zip Code:

Country:

Tel Day/Night:

Email:

Relationship to Deceased:

Kaddish Service- $540

Yahrzeit Service – $180

Extra Yahrzeit Kiddish – $90