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Information about the Deceased
First Name
Gender Male (ben) Female (bat)
Father's Jewish Name
(if known)
Relationship (father, mother, wife etc.)
Date of Passing
MM/DD/YYYY

After Nightfall?



Information about the Deceased - optional additional person
First Name
Gender Male (ben) Female (bat)
Father's Jewish Name
(if known)
Relationship (father, mother, wife etc.)
Date of Passing
MM/DD/YYYY

After Nightfall?


Information about Yourself
Name
Address
City  State: Zip:
Phone
Email

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To register more than two people, please submit this form multiple times.