Name of Deceased or
Pre-need Applicant
Date of Death
Place of Death
City,Town Village,State
County of Death
Residence
City,Town, Village
Zip Code
Date of Birth
Age
Place of Birth
Race
Marital Status
Level of Education
Social Security #
Occupation (please do
not enter retired)
Type of Industry
Surviving Spouse
Spouse's Maiden Name
Veteran ? Years?
Deceased Fathers
Name
Mother Maiden Name
Hispanic Origin
Next of Kin
Relationship
Address
City,State
Zip
Phone
Alternate Phone
E-Mail
Cemetery Name
Cemetery Location
Section
Block
Lot
Row
Line
Grave #
Society Name
Prior Interment
$ 7795.00 MOSES Solid Walnut
$ 5995.00 MORIAH Solid Cerry
$ 4995.00 SHEBAT Mahogany
$ 3995.00 JOSEPH Blond Poplar
$ 3495.00 OBIDIAH Beaded
$ 2995.00 RAMAH Oak
$ 2695.00 ZARA Orlando
$ 1995.00 DAN Stained
$ 1295.00 DAN Unstained Flat top
$ 895.00 PLAIN PINE
UNDECIDED
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casket here.
Please write any additional information or special instructions.
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expenses, the more we can continue
passing the savings on to the families we
serve.
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Jewish Newspaper
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Local Newspaper
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Other
Calendar
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You may also fax this to:
914-206-9616
This information will be transcribed onto a death certificate.
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