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			<h1 class="article-header__title js-article-title js-page-title">Yizkor Memorial Book</h1>
		
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<form class="userform-form" action="" method="post" name="form_7433560" id="7433560" accept-charset="utf-8"><input type="hidden" name="formID" value="7433560" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_17"><div id="cid_17" class="form-input-wide"> <div style="text-align:center;"><img alt="" class="form-image" border="0" src="https://w2.chabad.org/media/images/1293/UREv12938678.png" height="224" width="745" /></div> </div></li><li id="cid_18" class="form-input-wide"> <div class="form-header-group"><h2 id="header_18" class="form-header">Remember Your Loved Ones in Our Yizkor Memorial Book</h2><div id="subHeader_18" class="form-subHeader">The people we love remain part of our lives through the memories, values, and traditions they leave behind.<br /><br />Our annual Yizkor Memorial Book is a meaningful way to honor their memory and ensure that their names are remembered by our community during Yizkor services throughout the coming year.<br /><br />Through your memorial listing or dedication, their memory also helps sustain meaningful prayer, Jewish learning, and a warm, caring Jewish community.<br /><br />Please use the form below to submit or confirm the names of your loved ones.</div></div> </li><li id="cid_45" class="form-input-wide"> <div class="form-header-group"><h2 id="header_45" class="form-header">Your Information</h2></div> </li><li class="form-line" id="id_46"><div class="form-label-left" id="label_46"><label for="input_46"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_46"> </label></div><div id="cid_46" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q46_fullName46[first]" id="first_46" autocomplete="given-name" />  <label class="form-sub-label" for="first_46" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q46_fullName46[last]" id="last_46" autocomplete="family-name" />  <label class="form-sub-label" for="last_46" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_47"><div class="form-label-left" id="label_47"><label for="input_47"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_47"> </label></div><div id="cid_47" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_47" name="q47_email47" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_48"><div class="form-label-left" id="label_48"><label for="input_48"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_48"> </label></div><div id="cid_48" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q48_phoneNumber[full]" id="input_48_full" autocomplete="tel" />  <label class="form-sub-label" for="input_48_full"><span> </span></label></span></div> </div></li><li id="cid_19" class="form-input-wide"> <div class="form-header-group"><h2 id="header_19" class="form-header">Need help with Hebrew names, dates, or several memorial listings?</h2><div id="subHeader_19" class="form-subHeader">Please share whatever information you know. It is completely fine to leave an item blank, and we will be happy to help with the rest.</div></div> </li><li id="cid_52" class="form-input-wide"> <div class="form-header-group"><h2 id="header_52" class="form-header">Choose How You Would Like to Remember Your Loved Ones</h2><div id="subHeader_52" class="form-subHeader">Whether you choose a simple memorial listing or a personal dedication, every tribute is prepared with care and gratitude.</div></div> </li><li class="form-line" id="id_65"><div class="form-label-left" id="label_65"><label for="input_65"> Memorial Listing $18 per name </label><label class="label-message" for="input_65"> </label></div><div id="cid_65" class="form-input"> <span class="form-sub-label-container"><input type="number" class="form-number-input  form-textbox" id="input_65" name="q65_number" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" />  <label class="form-sub-label" for="input_65">Include the name of a loved one in this year’s Yizkor Memorial Book and have them remembered during Yizkor services throughout the coming year.</label></span> </div></li><li class="form-line" id="id_66"><div class="form-label-left" id="label_66"><label for="input_66"> Half-Page Dedication $72 </label><label class="label-message" for="input_66"> </label></div><div id="cid_66" class="form-input"> <span class="form-sub-label-container"><input type="number" class="form-number-input  form-textbox" id="input_66" name="q66_number66" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" />  <label class="form-sub-label" for="input_66">Create a personal tribute featuring the names of your loved ones and a brief dedication or message.Memorial listings for everyone named in your tribute are included.</label></span> </div></li><li class="form-line" id="id_67"><div class="form-label-left" id="label_67"><label for="input_67"> Full-Page Dedication $136 </label><label class="label-message" for="input_67"> </label></div><div id="cid_67" class="form-input"> <span class="form-sub-label-container"><input type="number" class="form-number-input  form-textbox" id="input_67" name="q67_number67" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" />  <label class="form-sub-label" for="input_67">Create a prominent full-page tribute with space to honor one or more loved ones, share a meaningful message, or remember the legacy they left behind.Memorial listings for everyone named in your tribute are included.</label></span> </div></li><li class="form-line always-hidden" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> Memorial Listing $18 per name </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_20_0" name="q20_input20[]" value="Include the name of a loved one in this year’s Yizkor Memorial Book and have them remembered during Yizkor services throughout the coming year." /><label id="label_input_20_0" for="input_20_0"><span>Include the name of a loved one in this year’s Yizkor Memorial Book and have them remembered during Yizkor services throughout the coming year.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line always-hidden" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> Half-Page Dedication $72 </label><label class="label-message" for="input_21"> </label></div><div id="cid_21" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_21_0" name="q21_input21[]" value="Create a personal tribute featuring the names of your loved ones and a brief dedication or message.Memorial listings for everyone named in your tribute are included." /><label id="label_input_21_0" for="input_21_0"><span>Create a personal tribute featuring the names of your loved ones and a brief dedication or message.Memorial listings for everyone named in your tribute are included.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line always-hidden" id="id_22"><div class="form-label-left" id="label_22"><label for="input_22"> Full-Page Dedication $136 </label><label class="label-message" for="input_22"> </label></div><div id="cid_22" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_22_0" name="q22_input22[]" value="Create a prominent full-page tribute with space to honor one or more loved ones, share a meaningful message, or remember the legacy they left behind.Memorial listings for everyone named in your tribute are included." /><label id="label_input_22_0" for="input_22_0"><span>Create a prominent full-page tribute with space to honor one or more loved ones, share a meaningful message, or remember the legacy they left behind.Memorial listings for everyone named in your tribute are included.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_23"><div class="form-label-left" id="label_23"><label for="input_23"> Permanent Memorial Plaque <br /> $500 </label><label class="label-message" for="input_23"> </label></div><div id="cid_23" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_23_0" name="q23_input23[]" value="Create a lasting tribute to someone you love with a permanent memorial plaque displayed at Chabad of Fairfield.Their name will also be included in our Yizkor Memorial Book each year, ensuring that they continue to be remembered by our community for generations to come." /><label id="label_input_23_0" for="input_23_0"><span>Create a lasting tribute to someone you love with a permanent memorial plaque displayed at Chabad of Fairfield.Their name will also be included in our Yizkor Memorial Book each year, ensuring that they continue to be remembered by our community for generations to come.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_24"><div class="form-label-left" id="label_24"><label for="input_24"> Included for Chai Club Members  </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_24_0" name="q24_input24[]" value="If you are a current Chai Club member or your family has previously dedicated a permanent memorial plaque, your memorial listings are included with our gratitude. Please use this form to confirm the names we have on file or share any updates." /><label id="label_input_24_0" for="input_24_0"><span>If you are a current Chai Club member or your family has previously dedicated a permanent memorial plaque, your memorial listings are included with our gratitude. Please use this form to confirm the names we have on file or share any updates.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_63"><div class="form-label-left" id="label_63"><label for="input_63"> Included for Memorial Plaque Families </label><label class="label-message" for="input_63"> </label></div><div id="cid_63" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_63_0" name="q63_input63[]" value="If your family has previously dedicated a permanent memorial plaque, your family’s memorial listings are included with our gratitude.  Please use this form to confirm the names we have on file or share any updates." /><label id="label_input_63_0" for="input_63_0"><span>If your family has previously dedicated a permanent memorial plaque, your family’s memorial listings are included with our gratitude.  Please use this form to confirm the names we have on file or share any updates.</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_25" class="form-input-wide"> <div class="form-header-group"><h2 id="header_25" class="form-header">Tell Us Whom You Would Like to Remember</h2></div> </li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Do we already have your family’s memorial names on file? </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_26_0" name="q26_input26" value="Yes, please include all the names currently on file." /><label id="label_input_26_0" for="input_26_0"><span>Yes, please include all the names currently on file.</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_26_1" name="q26_input26" value="I would like to review, update, or add names below." /><label id="label_input_26_1" for="input_26_1"><span>I would like to review, update, or add names below.</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_26_2" name="q26_input26" value="I am not sure. Please contact me to confirm." /><label id="label_input_26_2" for="input_26_2"><span>I am not sure. Please contact me to confirm.</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_27"><div id="cid_27" class="form-input-wide"> <div id="text_27" class="form-html"><h2>First Memorial Name</h2>

<p>Please share as much information as you know. It is completely fine to leave an item blank.</p>
</div> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> English Name </label><label class="label-message" for="input_28"> </label></div><div id="cid_28" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q28_fullName28[first]" id="first_28" autocomplete="given-name" />  <label class="form-sub-label" for="first_28" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q28_fullName28[last]" id="last_28" autocomplete="family-name" />  <label class="form-sub-label" for="last_28" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> Hebrew Name, if known </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_29" name="q29_input29" size="20" value="" /> </div></li><li class="form-line" id="id_30"><div class="form-label-left" id="label_30"><label for="input_30"> Father’s Hebrew Name, if known </label><label class="label-message" for="input_30"> </label></div><div id="cid_30" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_30" name="q30_input30" size="20" value="" /> </div></li><li class="form-line" id="id_31"><div class="form-label-left" id="label_31"><label for="input_31"> Date of Passing, if known </label><label class="label-message" for="input_31"> </label></div><div id="cid_31" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q31_birthDate[month]" id="input_31_month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_31_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q31_birthDate[day]" id="input_31_day"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_31_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q31_birthDate[year]" id="input_31_year"><option></option><option value="2026">2026</option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_31_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_32"><div class="form-label-left" id="label_32"><label for="input_32"> Relationship to you </label><label class="label-message" for="input_32"> </label></div><div id="cid_32" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_32" name="q32_input32" size="20" value="" /> </div></li><li class="form-line" id="id_58"><div class="form-label-left" id="label_58"><label for="input_58"> Would you like to receive an annual Yahrzeit reminder? </label><label class="label-message" for="input_58"> </label></div><div id="cid_58" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_58_0" name="q58_input58" value="Yes" /><label id="label_input_58_0" for="input_58_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_58_1" name="q58_input58" value="No" /><label id="label_input_58_1" for="input_58_1"><span>No</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_58_2" name="q58_input58" value="I already receive reminders" /><label id="label_input_58_2" for="input_58_2"><span>I already receive reminders</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_40"><div class="form-label-left" id="label_40"><label for="input_40">  </label><label class="label-message" for="input_40"> </label></div><div id="cid_40" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_40_0" name="q40_input40[]" value="I would like to add an additional Memorial Name" /><label id="label_input_40_0" for="input_40_0"><span>I would like to add an additional Memorial Name</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_34"><div id="cid_34" class="form-input-wide"> <div id="text_34" class="form-html"><h2>Second Memorial Name</h2>

<p>Please share as much information as you know. It is completely fine to leave an item blank.</p>
</div> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> English Name </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q35_fullName35[first]" id="first_35" autocomplete="given-name" />  <label class="form-sub-label" for="first_35" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q35_fullName35[last]" id="last_35" autocomplete="family-name" />  <label class="form-sub-label" for="last_35" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_36"><div class="form-label-left" id="label_36"><label for="input_36"> Hebrew Name, if known </label><label class="label-message" for="input_36"> </label></div><div id="cid_36" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_36" name="q36_input36" size="20" value="" /> </div></li><li class="form-line" id="id_37"><div class="form-label-left" id="label_37"><label for="input_37"> Father's Hebrew Name, if known </label><label class="label-message" for="input_37"> </label></div><div id="cid_37" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_37" name="q37_input37" size="20" value="" /> </div></li><li class="form-line" id="id_38"><div class="form-label-left" id="label_38"><label for="input_38"> Date of Passing, if known </label><label class="label-message" for="input_38"> </label></div><div id="cid_38" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q38_birthDate38[month]" id="input_38_month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_38_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q38_birthDate38[day]" id="input_38_day"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_38_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" name="q38_birthDate38[year]" id="input_38_year"><option></option><option value="2026">2026</option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_38_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_39"><div class="form-label-left" id="label_39"><label for="input_39"> Relationship to you </label><label class="label-message" for="input_39"> </label></div><div id="cid_39" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_39" name="q39_input39" size="20" value="" /> </div></li><li class="form-line" id="id_59"><div class="form-label-left" id="label_59"><label for="input_59"> Would you like to receive an annual Yahrzeit reminder? </label><label class="label-message" for="input_59"> </label></div><div id="cid_59" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_59_0" name="q59_input59" value="Yes" /><label id="label_input_59_0" for="input_59_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_59_1" name="q59_input59" value="No" /><label id="label_input_59_1" for="input_59_1"><span>No</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_59_2" name="q59_input59" value="I already receive reminders" /><label id="label_input_59_2" for="input_59_2"><span>I already receive reminders</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_41"><div id="cid_41" class="form-input-wide"> <div id="text_41" class="form-html"><h2>Need to include several names?</h2>

<p>You may also enter them in the notes section below or contact us. We will be glad to help.</p>
</div> </div></li><li id="cid_62" class="form-input-wide"> <div class="form-header-group"><h2 id="header_62" class="form-header">Personalize Your Dedication</h2></div> </li><li class="form-line" id="id_61"><div class="form-label-left" id="label_61"><label for="input_61"> Names to Include </label><label class="label-message" for="input_61"> </label></div><div id="cid_61" class="form-input"> <span class="form-sub-label-container"><textarea id="input_61" class="form-textarea" name="q61_input61" cols="40" rows="6"></textarea>  <label class="form-sub-label" for="input_61">Please list the names exactly as you would like them to appear.</label></span> </div></li><li class="form-line" id="id_44"><div class="form-label-left" id="label_44"><label for="input_44"> Dedication or Memorial Message </label><label class="label-message" for="input_44"> </label></div><div id="cid_44" class="form-input"> <span class="form-sub-label-container"><textarea id="input_44" class="form-textarea" name="q44_input44" cols="40" rows="6"></textarea>  <label class="form-sub-label" for="input_44">You may include a brief message, a meaningful memory, <br /> or a few words about the legacy your loved ones left behind.</label></span> </div></li><li class="form-line" id="id_49"><div class="form-label-left" id="label_49"><label for="input_49"> Special Instructions </label><label class="label-message" for="input_49"> </label></div><div id="cid_49" class="form-input"> <span class="form-sub-label-container"><textarea id="input_49" class="form-textarea" name="q49_input49" cols="40" rows="6"></textarea>  <label class="form-sub-label" for="input_49">Please share any layout requests or additional details you would like us to know.</label></span> </div></li><li class="form-line" id="id_64"><div id="cid_64" class="form-input-wide"> <div id="text_64" class="form-html"><hr />

</div> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Total Memorial Gift </label></div><div id="cid_12" class="form-input"> <div id="total_amount">$0.00 </div><div class="form-single-column form-checkbox-item" id="div_offset_gift_12" style="padding-top: 10px">          <input type="checkbox" id="input_12" class="form-checkbox" name="q12_offsetGiftPercent" value="3" />            <label id="label_12" for="input_12">Yes, I'd like to donate the cost of processing this transaction by adding 3%</label>                <input type="hidden" id="hidden_12" name="q12_offsetGiftAmount" />              <div class="clearfix"></div>            </div> </div></li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> Payment Method </label><label class="label-message" for="input_15"> </label></div><div id="cid_15" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_15_creditCard" name="q15_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_15_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_15_paypal" name="q15_payment[payment_method]" value="paypal" onclick="BuildSource.paypal(this)" /><label for="input_15_paypal">Paypal</label> </span></td></tr><tr class="credit_card hide"><th colspan="2">Credit Card</th></tr><tr class="credit_card hide"><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, Discover</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q15_payment[cc_type]" id="input_15_cc_type" value="" /></td></tr><tr><td><div class="cc-field-wrapper"><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[visible, creditcard]" type="text" name="q15_payment[cc_number]" id="input_15_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_15_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q15_payment[cc_ccv]" id="input_15_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_15_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr><td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q15_payment[cc_nameOnCard]" id="input_15_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_15_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card hide"><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q15_payment[cc_exp_month]" id="input_15_cc_exp_month" autocomplete="cc-exp-month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_15_cc_exp_month" id="sublabel_cc_exp_month">Expiration Month</label></span></td><td><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q15_payment[cc_exp_year]" id="input_15_cc_exp_year" autocomplete="cc-exp-year"><option></option><option value="2026">2026</option><option value="2027">2027</option><option value="2028">2028</option><option value="2029">2029</option><option value="2030">2030</option><option value="2031">2031</option><option value="2032">2032</option><option value="2033">2033</option><option value="2034">2034</option><option value="2035">2035</option></select>  <label class="form-sub-label" for="input_15_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="paypal hide"><td colspan="2">Paypal has been selected. Payment will take place on the next page.</td></tr><tr class="billing_address hide"><th colspan="2">Billing Address</th></tr><tr class="billing_address hide"><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q15_payment[addr_line1]" id="input_15_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_15_addr_line1" id="sublabel_15_addr_line1">Street Address</label></span></td></tr><tr class="billing_address hide"><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q15_payment[city]" id="input_15_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_15_city" id="sublabel_15_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q15_payment[state]" id="input_15_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_15_state" id="sublabel_15_state">State / Province</label></span></td></tr><tr class="billing_address hide"><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q15_payment[postal]" id="input_15_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_15_postal" id="sublabel_15_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q15_payment[country]" id="input_15_country" autocomplete="billing country-name"><option value="" selected="selected">Please Select</option><option value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option 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value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi 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