Bereavement Information
Source Form
DECEASED INFORMATION
First Name of Deceased
Last Name of Deceased
Date of Death
Were they a member of WHC?
Yes
No
Age
FAMILY INFORMATION
PARTNER/SPOUSE OF THE DECEASED
Name of Partner/Spouse
Husband
Wife
Partner
Spouse
WHC Member?
Yes
No
CHILDREN OF THE DECEASED
Please add in order of eldest to youngest.
Name of Child. Include name of partner/spouse in parentheses.
Child
Daughter
Son
WHC Member?
Yes
No
GRANDCHILDREN OF THE DECEASED
Please add in order of eldest to youngest.
Name of Grandchild. Include name of partner/spouse in parentheses.
Grandchild
Granddaughter
Grandson
WHC Member?
Yes
No
GREAT-GRANDCHILDREN
OF THE DECEASED
Please add in order of eldest to youngest.
Name of Great-Grandchild.
Great-Grandchild
Great-Granddaughter
Great-Grandson
SIBLINGS OF THE DECEASED
Name of Sibling.
Include name of partner/spouse in parentheses.
Brother
Sister
Sibling
WHC Member?
Yes
No
Any additional people you would like to list?
POINT PERSON INFORMATION
First Name
Last Name
Phone Number
Email Address
Street Address
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Islands
Northern Mariana Islands
Guam
American Samoa
Palau
Zip Code
DONATIONS
Where should donations be directed?
Donation Link
ADDITIONAL INFORMATION
Are any WHC clergy officiating at the funeral?
Yes
No
Are you working with Sagel Bloomfield Funeral Home?
Yes
No
There is an officiation fee if WHC clergy are involved. Would you like to pay now?
Yes
No
Email condolences list? This is a list of WHC members who have asked to be notified of deaths of congregants and/or their family members.
Yes
No
Would you like to include
Funeral Information
Shiva Information
Are you interested in purchasing a memorial plaque in honor of the deceased?
Yes
No
TOTAL COST
Officiation donation fees for funerals are $750 for Temple Members, $1,800 for Non-Members.
$
Admin Code (Staff Use Only)
Please select...
Yes
No
Enter Admin Code
Amount Due Today
Would you like to make an additional donation to the Lewis S. Wiener Annual Fund supporting the Temple's greatest financial need? Enter the amount below.
$
This donation is from:
Total Amount
$
PAYMENT METHOD
How would you like to pay your bill?
Credit Card (includes 3% fee)
ACH (Direct Bank Debit - No fee)
CREDIT CARD INFORMATION
To help defray some of WHC's credit card processing costs, a 3% fee has been added to your credit card payment. Please note that ACH payments do not include this fee.
Fee Amount
$
Grand Total
$
First Name on Card
Last Name on Card
Credit Card Number
Expiration Month
Please select...
01
02
03
04
05
06
07
08
09
10
11
12
Expiration Year
Please select...
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
CVV
Different billing address?
Please select...
No
Yes
Billing Street
Billing City
Billing State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Billing Zip Code
ACH INFORMATION
Bank Routing Number
Bank Account Number
Bank Account Type
Checking
Savings
Bank Name
Account Holder's Name (
NOTE: If this is a joint account, use one name only. If it's a trust/foundation use one first/last name only
)
Different billing address?
Please select...
No
Yes
Billing Street
Billing City
Billing State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Billing Zip Code
DO NOT CLICK THE SUBMIT BUTTON MORE THAN ONCE TO AVOID ADDITIONAL CHARGES
After you click SUBMIT, you will be given the opportunity to review your information. Please check it carefully before confirming.
ENTER STAFF CODE
Form Status
Pending
Informational
Ready to Send
FUNERAL INFORMATION
Funeral Home
Please select...
Sagel-Bloomfield
Torchinsky
Gawler
Other
Which Funeral Home?
Funeral Home Phone
Funeral Home Director
Date of Service
Time of Service
Type of Service
Funeral
Memorial Service
Location of Service
Please select...
Temple - Sanctuary
Temple - Chapel
JBSC
Garden of Remembrance
Memorial Park (Alabama Ave. SE)
King David Cemetery
Other
Where is the service being held?
Graveside?
Yes
No
Cemetery
Please select...
Garden of Remembrance
Memorial Park (Alabama Ave. SE)
King David Cemetery
Other
WHC Lot #
Which cemetery?
Service Livestream Link
Service Livestream Meeting ID
Service Livestream Password
Officiating Clergy
Rabbi Shankman
Rabbi Miller
Rabbi Fischel
Rabbi Schmelkin
Cantor Bortnick
Cantor Hamstra
Non-WHC Clergy
Additional Funeral Info
Vault Required
Liner Required
Yahrzeit Plaques
Family Meeting Date
Family Meeting Time
Family Meeting Location
Family Meeting Zoom Meeting ID
Family Meeting Zoom Password
SHIVA INFORMATION
Shiva Date
Shiva Time
Shiva Location
Officiating Clergy
Rabbi Shankman
Rabbi Miller
Rabbi Fischel
Rabbi Schmelkin
Cantor Bortnick
Cantor Hamstra
Lay Leaders
NOTES
Publicly Hidden Fields
Payment Section
Hide Payment Info
Hidden
Portal Pre-Fill Fields
Account ID
Contact ID
Outreach/Event Pre-Fill
OutreachID
DesignationID
Auth.net Connector Billing Info
Gateway Address
Gateway City
Gateway State
Gateway Zip
Gateway Totals
Gateway Quantity
Gateway Amount
Authnet_Hidden_Fields