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Funeral and Shiva Information Intake Form
Please verify reCaptcha before submitting the form.
Please fill out the online form prior to speaking with Rabbi Cantor.
If you should need anything, please contact us at
215-493-1707 x4.
May the memory of your loved one be a blessing.
*
Last Name
*
First Name
*
Email
*
Cell number (ex. 123-456-7890)
*
Name of family member who passed:
Hebrew Name (if known):
*
When did loved one pass (Day and Date)?
*
When did loved one pass (Time)?
*
Type in yes or no. Did the decease pass away AFTER sunset?
Hebrew Date (if known)
Fill in the appropriate information below regarding the relationship to whomever is filling out form.
mother/father/sister/brother/husband/wife/grandmother/grandfather/uncle/aunt/step (mother, father, sister, brother, etc.)
of (Type in name below)
Please list family members and their relationship to your loved one.
1. Name of family member.
1. Relationship to the loved one.
2. Name of family member.
2. Relationship to the loved one.
3. Name of family member.
3. Relationship to the loved one.
4. Name of family member.
4. Relationship to the loved one.
5. Name of family member.
5. Relationship to the loved one.
6. Name of family member.
6. Relationship to the loved one.
7. Name of family member.
7. Relationship to the loved one.
8. Name of family member.
8. Relationship to the loved one.
9. Name of family member.
9. Relationship to the loved one.
10. Name of family member.
10. Relationship to the loved one.
When is the funeral (Date and Time)?
Where is the funeral (list address)?
Interment (list cemetery name and address):
Shiva Minyan Information (Name and address of where the family is sitting):
Shiva Minyan Information (Day and Times):
Shiva Minyan Information (Day and Times):
Shiva Minyan Information (Days and Times):
Shiva Minyan Information (Day and Times):
Shiva Minyan Information (Day and Times):
Shiva Minyan Information (Day and Times):
Shiva Minyan Information (Day and Times):
Use this space if a different home will be holding Shiva Minyan (Name/address/day/time):
Do you want to say Kaddish on your own or do you want Rabbi Cantor to lead?
N/A
Yes, we would like Rabbi Cantor to lead minyan services
No, we do not need Rabbi Cantor to lead minyan services
Will donations be made to Congregation Beth El? Any specific fund.
Will there be donations made to an outside organization? List name, address/email/website link.
Would you like us to share your email and address for consolation notes to be sent to you?
Zoom services at Beth El (if funeral is being held in the sanctuary).
N/A
Yes
No
Record services at Beth El (if funeral is being held in the sanctuary).
N/A
Yes
No
Livestream (YouTube) Services at Beth El (if funeral is being held in the sanctuary).
N/A
Yes
No
Would you like us to send you a Shiva meal?
N/A
Yes
No
Day meal will be delivered. If on Friday, the meal will be for Shabbat.
No thank you
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
How many people?
0
1
2
3
4
5
6
7
8
9
10
Dietary restrictions:
Deliver on: (day/time preferred)
Delivered to (name/address/contact number):
Is there anything you would like the congregation to know about your loved one?
Sat, June 14 2025 18 Sivan 5785
