JEWISH MEMORIAL CHAPEL
1-800-617-2303
914-965-0660

Information Sheet

Information Sheet

This information will be transcribed onto a death certificate. Your information will not be shared with any third parties. 

Name of Deceased or Pre-need Applicant:
Date of Death:
Place of Death:
City of Death:
County of Death:
   
Legal Home Address:
City Town Village:
State
Zip Code
   
Marital Status:
Name of Spouse: (if living)
Maiden Name of Spouse: (if living)
Date of Birth:
Age:
Social Security Number:
Place of Birth: City,State or Country
Race:
Level of Education
 9-12, HS, Some College,BA,MA,PHD Etc. 
Mother's First name & Maiden name:
Father's First & Last Name :
Hispanic Origin? if yes specify :
Veteran? (if yes, specify branch, years, war etc.):
Occupation: (do not enter retired)
Type of Industry:
   
Next of Kin:
Relationship:
Home Address:
City :
State & Zip Code:
Home Phone:
Cell Phone:
Email:
   
Cemetery:
Location: (City & State)
Section:
Block/ Lot:
Row/ Line:
Grave:
Prior Burial :
Society Name :
 CASKET SELECTION
 
  $5995.00 MORIAH Solid Cherry
  $5495.00 SHEBAT Mahogany
  $4895.00 DAVID Oak
  $3995.00 MIRIAM Poplar
  $3495.00 OBIDIAH Beaded Poplar
  $2995.00 RAMAH Solid Oak
  $2695.00 ROSH Polished Mahogany Finish Poplar
  $1995.00 SIMION Stained poplar
  $1295.00 DAN Un-Stained poplar
  $895.00 Pine (no interior or pillow)
Notes :

Please feel free to include any requests or concerns you may have. 
 HOW DID YOU
HEAR ABOUT US ?

We try to closely monitor our advertising budget in order  pass on substantial savings to the families we serve. Thank you in advance for filling out this form.  
  Phone Book
  Google
  Yahoo!
  Other internet search
  Online Yellow Pages
  Cable Television
  Newspaper / Publication

Referral
  Other
You may also print and fax this form to 914-206-9616
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