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	KOL NIDREI APPEAL & YIZKOR BOOKLET - Chabad of the Delta
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			<h1 class="article-header__title js-article-title js-page-title">KOL NIDREI APPEAL & YIZKOR BOOKLET</h1>
		
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window.formJson = Object.extend([{"form_height":991,"34_text":"\u003cp\u003eDear Friend,\u003c/p\u003e\n\n\u003cp\u003eWe are writing to let you know that the Chabad of the Delta will publish a \u0026quot;Yizkor Memorial Booklet\u0026quot;, in time for Yom Kippur 2024-2025\u0026nbsp;/ 5785.\u0026nbsp;The booklet will contain\u0026nbsp; all the Yizkor prayers in Hebrew and English. In addition, it will feature a separate section\u0026nbsp; listing the names of departed souls and the family members you wish to be remembered. The booklet will be available at Chabad, in the upcoming year, each time Yizkor is recited and will\u0026nbsp; honor those family members who have passed on to their eternal reward.\u003c/p\u003e\n\n\u003cp\u003eWhether you will participate in the Yizkor service or will stay at home, this is a great way to honor your loved ones.\u0026nbsp;\u003c/p\u003e\n\n\u003cp\u003ePlease complete the form below and submit payment.\u003c/p\u003e\n\n\u003cp\u003eIf you would like to participate by giving tzedakah in memory of a deceased family member and having them listed in our yizkor booklet please see available dedication opportunities below.\u003c/p\u003e\n\n\u003cp\u003e\u003cem\u003eIf you would like to include all the names you already submitted\u0026nbsp;for yahrtzeit reminders or previous years Yizkor Booklet, \u003ca href=\"#Contribution\"\u003e\u003cspan style=\"color: rgb(0, 0, 255);\"\u003eCLICK HERE\u003c/span\u003e\u003c/a\u003e\u003c/em\u003e\u003cspan style=\"color: rgb(0, 0, 255);\"\u003e\u003cem\u003e.\u003c/em\u003e\u003c/span\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cem\u003eIf you don\u0026#39;t know the Jewish or Father\u0026#39;s Jewish name or date etc. Just fill what you know!\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n","34_name":"doubleclickTo","34_qid":34,"34_type":"control_text","34_order":1,"54_text":"Your info","54_subHeader":"","54_headerType":"Default","54_name":"clickTo54","54_qid":54,"54_type":"control_head","54_order":2,"43_text":"Your Full Name","43_message":"","43_labelAlign":"Auto","43_required":"No","43_prefix":"No","43_suffix":"No","43_middle":"No","43_description":"","43_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"43_readonly":"No","43_name":"fullName","43_qid":43,"43_type":"control_fullname","43_order":3,"51_receivesReceipts":"No","51_text":"E-mail","51_message":"","51_labelAlign":"Auto","51_required":"No","51_size":30,"51_validation":"Email","51_maxsize":"","51_defaultValue":"","51_subLabel":"","51_hint":"ex: myname@example.com","51_description":"","51_confirmation":"No","51_confirmationHint":"Confirm Email","51_readonly":"No","51_name":"email51","51_qid":51,"51_type":"control_email","51_order":4,"52_text":"Phone Number","52_message":"","52_labelAlign":"Auto","52_required":"No","52_validation":"Numeric","52_countryCode":"No","52_inputMask":"disable","52_inputMaskValue":"(###) ###-####","52_description":"","52_sublabels":{"country":"Country Code","area":"Area Code","phone":"Phone Number","full":"Phone Number"},"52_readonly":"No","52_name":"phoneNumber52","52_qid":52,"52_type":"control_phone","52_order":5,"53_text":"Address","53_message":"","53_labelAlign":"Auto","53_required":"No","53_selectedCountry":"","53_description":"","53_subfields":"st1|st2|city|state|zip|country","53_sublabels":{"cc_firstName":"First Name","cc_lastName":"Last Name","cc_number":"Credit Card Number","cc_ccv":"Security Code","cc_exp_month":"Expiration Month","cc_exp_year":"Expiration Year","addr_line1":"Street Address","addr_line2":"Street Address Line 2","city":"City","state":"State / Province","postal":"Postal / Zip Code","country":"Country"},"53_name":"address53","53_qid":53,"53_type":"control_address","53_order":6,"38_text":"\u003cp\u003e\u0026#160;Already submitted your names for\u0026#160;\u003ca name=\"Contribution\"\u003eA\u0026#160;\u0026#160;\u003c/a\u003eYahrtziet reminder?\u003c/p\u003e\u003cp\u003eSimply check the box below. no need to resubmit!\u0026#160;\u003c/p\u003e","38_name":"doubleclickTo38","38_qid":38,"38_type":"control_text","38_order":7,"35_text":"Include all Yahrtziet reminders","35_message":"","35_labelAlign":"Auto","35_required":"No","35_options":"Please include all the names I have in the Yahrtziet Reminder","35_special":"None","35_allowOther":"No","35_otherText":"Other","35_calculateOther":"No","35_spreadCols":"1","35_selected":"","35_minSelection":"","35_maxSelection":"","35_description":"","35_name":"input35","35_qid":35,"35_type":"control_checkbox","35_order":8,"35_pricing":"0","48_text":"\u003cp\u003eA contribution of $25\u0026nbsp;per name is requested. 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<form class="userform-form" action="" method="post" name="form_4891410" id="4891410" accept-charset="utf-8"><input type="hidden" name="formID" value="4891410" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_34"><div id="cid_34" class="form-input-wide"> <div id="text_34" class="form-html"><p>Dear Friend,</p>

<p>We are writing to let you know that the Chabad of the Delta will publish a "Yizkor Memorial Booklet", in time for Yom Kippur 2024-2025 / 5785. The booklet will contain  all the Yizkor prayers in Hebrew and English. In addition, it will feature a separate section  listing the names of departed souls and the family members you wish to be remembered. The booklet will be available at Chabad, in the upcoming year, each time Yizkor is recited and will  honor those family members who have passed on to their eternal reward.</p>

<p>Whether you will participate in the Yizkor service or will stay at home, this is a great way to honor your loved ones. </p>

<p>Please complete the form below and submit payment.</p>

<p>If you would like to participate by giving tzedakah in memory of a deceased family member and having them listed in our yizkor booklet please see available dedication opportunities below.</p>

<p><em>If you would like to include all the names you already submitted for yahrtzeit reminders or previous years Yizkor Booklet, <a href="#Contribution"><span style="color: rgb(0, 0, 255);">CLICK HERE</span></a></em><span style="color: rgb(0, 0, 255);"><em>.</em></span></p>

<p><em>If you don't know the Jewish or Father's Jewish name or date etc. Just fill what you know! </em></p>
</div> </div></li><li id="cid_54" class="form-input-wide"> <div class="form-header-group"><h2 id="header_54" class="form-header">Your info</h2></div> </li><li class="form-line" id="id_43"><div class="form-label-left" id="label_43"><label for="input_43"> Your Full Name </label><label class="label-message" for="input_43"> </label></div><div id="cid_43" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q43_fullName[first]" id="first_43" autocomplete="given-name" />  <label class="form-sub-label" for="first_43" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q43_fullName[last]" id="last_43" autocomplete="family-name" />  <label class="form-sub-label" for="last_43" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_51"><div class="form-label-left" id="label_51"><label for="input_51"> E-mail </label><label class="label-message" for="input_51"> </label></div><div id="cid_51" class="form-input"> <input type="email" class=" form-textbox validate[Email]" id="input_51" name="q51_email51" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_52"><div class="form-label-left" id="label_52"><label for="input_52"> Phone Number </label><label class="label-message" for="input_52"> </label></div><div id="cid_52" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q52_phoneNumber52[area]" id="input_52_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_52_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q52_phoneNumber52[phone]" id="input_52_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_52_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_53"><div class="form-label-left" id="label_53"><label for="input_53"> Address </label><label class="label-message" for="input_53"> </label></div><div id="cid_53" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q53_address53[addr_line1]" id="input_53_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_53_addr_line1" id="sublabel_53_addr_line1">Street Address</label></span></td></tr><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q53_address53[addr_line2]" id="input_53_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_53_addr_line2" id="sublabel_53_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q53_address53[city]" id="input_53_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_53_city" id="sublabel_53_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q53_address53[state]" id="input_53_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_53_state" id="sublabel_53_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q53_address53[postal]" id="input_53_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_53_postal" id="sublabel_53_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q53_address53[country]" id="input_53_country" autocomplete="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 value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option 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 Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tristan da Cunha">Tristan da Cunha</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="British Virgin Islands">British Virgin Islands</option><option value="US Virgin Islands">US Virgin Islands</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="other">Other</option></select>  <label class="form-sub-label" for="input_53_country" id="sublabel_53_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_38"><div id="cid_38" class="form-input-wide"> <div id="text_38" class="form-html"><p> Already submitted your names for <a name="Contribution">A  </a>Yahrtziet reminder?</p><p>Simply check the box below. no need to resubmit! </p></div> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> Include all Yahrtziet reminders </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_35_0" name="q35_input35[]" value="Please include all the names I have in the Yahrtziet Reminder" /><label id="label_input_35_0" for="input_35_0"><span>Please include all the names I have in the Yahrtziet Reminder</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_48"><div id="cid_48" class="form-input-wide"> <div id="text_48" class="form-html"><p>A contribution of $25 per name is requested. Or any amount you would like.</p>
</div> </div></li><li class="form-line" id="id_37"><div class="form-label-left" id="label_37"><label for="input_37"> # of Names:  </label><label class="label-message" for="input_37"> Charge me $25 per name</label></div><div id="cid_37" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_37" name="q37_number" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li class="form-line" id="id_40"><div class="form-label-left" id="label_40"><label for="input_40"> I would like to place a Dedication Ad in memory of a loved one: </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="Booklet Sponsor $540" /><label id="label_input_40_0" for="input_40_0"><span>Booklet Sponsor $540</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_40_1" name="q40_input40[]" value="Full Dedication Page Ad $360" /><label id="label_input_40_1" for="input_40_1"><span>Full Dedication Page Ad $360</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_40_2" name="q40_input40[]" value="Half Dedication Page Ad $180" /><label id="label_input_40_2" for="input_40_2"><span>Half Dedication Page Ad $180</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Optional Donation (different amount) </label><label class="label-message" for="input_41"> </label></div><div id="cid_41" class="form-input"> <div class="form-single-column"><span class="form-radio-item simple-mode"><label id="label_input_41" for="input_41"><span>$</span></label><input type="number" class="form-textbox" id="input_41" name="q41_input41" value="" onkeypress="validateNumber(event)" /></span><span class="clearfix"></span></div> </div></li><li id="cid_49" class="form-input-wide"> <div class="form-header-group"><h2 id="header_49" class="form-header">In loving memory</h2></div> </li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> Full Name 1 </label><label class="label-message" for="input_5"> </label></div><div id="cid_5" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q5_fullName5[first]" id="first_5" autocomplete="given-name" />  <label class="form-sub-label" for="first_5" id="sublabel_first">Civil Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q5_fullName5[middle]" id="middle_5" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_5" id="sublabel_middle">Jewish Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q5_fullName5[last]" id="last_5" autocomplete="family-name" />  <label class="form-sub-label" for="last_5" id="sublabel_last">Father's Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="4" name="q5_fullName5[suffix]" id="suffix_5" autocomplete="honorific-suffix" />  <label class="form-sub-label" for="suffix_5" id="sublabel_suffix">Last Name</label></span> </div></li><li class="form-line" id="id_3"><div class="form-label-left" id="label_3"><label for="input_3"> Date of Passing 1 </label><label class="label-message" for="input_3"> </label></div><div id="cid_3" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_3" name="q3_input3[month]" type="tel" size="2" maxlength="2" value="08" />  <label class="form-sub-label" for="month_3" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_3" name="q3_input3[day]" type="tel" size="2" maxlength="2" value="31" />  <label class="form-sub-label" for="day_3" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_3" name="q3_input3[year]" type="tel" size="4" maxlength="4" value="2025" />  <label class="form-sub-label" for="year_3" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_3_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_3_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_4"><div class="form-label-left" id="label_4"><label for="input_4"> Relationship 1 </label><label class="label-message" for="input_4"> e.g. Mother, Father, Friend </label></div><div id="cid_4" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_4" name="q4_input4" size="20" value="" /> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> Full Name 2 </label><label class="label-message" for="input_14"> </label></div><div id="cid_14" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q14_fullName14[first]" id="first_14" autocomplete="given-name" />  <label class="form-sub-label" for="first_14" id="sublabel_first">Civil Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q14_fullName14[middle]" id="middle_14" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_14" id="sublabel_middle">Jewish Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q14_fullName14[last]" id="last_14" autocomplete="family-name" />  <label class="form-sub-label" for="last_14" id="sublabel_last">Father's Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="4" name="q14_fullName14[suffix]" id="suffix_14" autocomplete="honorific-suffix" />  <label class="form-sub-label" for="suffix_14" id="sublabel_suffix">Last Name</label></span> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> Date of Passing 2 </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_20" name="q20_input20[month]" type="tel" size="2" maxlength="2" value="08" />  <label class="form-sub-label" for="month_20" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_20" name="q20_input20[day]" type="tel" size="2" maxlength="2" value="31" />  <label class="form-sub-label" for="day_20" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_20" name="q20_input20[year]" type="tel" size="4" maxlength="4" value="2025" />  <label class="form-sub-label" for="year_20" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_20_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_20_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_32"><div class="form-label-left" id="label_32"><label for="input_32"> Relationship 2 </label><label class="label-message" for="input_32"> e.g. Mother, Father, Friend </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_13"><div class="form-label-left" id="label_13"><label for="input_13"> Full Name 3 </label><label class="label-message" for="input_13"> </label></div><div id="cid_13" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q13_fullName13[first]" id="first_13" autocomplete="given-name" />  <label class="form-sub-label" for="first_13" id="sublabel_first">Civil Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q13_fullName13[middle]" id="middle_13" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_13" id="sublabel_middle">Jewish Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q13_fullName13[last]" id="last_13" autocomplete="family-name" />  <label class="form-sub-label" for="last_13" id="sublabel_last">Father's Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="4" name="q13_fullName13[suffix]" id="suffix_13" autocomplete="honorific-suffix" />  <label class="form-sub-label" for="suffix_13" id="sublabel_suffix">Last Name</label></span> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Date of Passing 3 </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_19" name="q19_input19[month]" type="tel" size="2" maxlength="2" value="08" />  <label class="form-sub-label" for="month_19" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_19" name="q19_input19[day]" type="tel" size="2" maxlength="2" value="31" />  <label class="form-sub-label" for="day_19" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_19" name="q19_input19[year]" type="tel" size="4" maxlength="4" value="2025" />  <label class="form-sub-label" for="year_19" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_19_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_19_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_31"><div class="form-label-left" id="label_31"><label for="input_31"> Relationship 3 </label><label class="label-message" for="input_31"> e.g. Mother, Father, Friend </label></div><div id="cid_31" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_31" name="q31_input31" size="20" value="" /> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Full Name 4 </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q12_fullName12[first]" id="first_12" autocomplete="given-name" />  <label class="form-sub-label" for="first_12" id="sublabel_first">Civil Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q12_fullName12[middle]" id="middle_12" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_12" id="sublabel_middle">Jewish Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q12_fullName12[last]" id="last_12" autocomplete="family-name" />  <label class="form-sub-label" for="last_12" id="sublabel_last">Father's Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="4" name="q12_fullName12[suffix]" id="suffix_12" autocomplete="honorific-suffix" />  <label class="form-sub-label" for="suffix_12" id="sublabel_suffix">Last Name</label></span> </div></li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> Date of Passing 4 </label><label class="label-message" for="input_18"> </label></div><div id="cid_18" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_18" name="q18_input18[month]" type="tel" size="2" maxlength="2" value="08" />  <label class="form-sub-label" for="month_18" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_18" name="q18_input18[day]" type="tel" size="2" maxlength="2" value="31" />  <label class="form-sub-label" for="day_18" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_18" name="q18_input18[year]" type="tel" size="4" maxlength="4" value="2025" />  <label class="form-sub-label" for="year_18" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_18_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_18_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_30"><div class="form-label-left" id="label_30"><label for="input_30"> Relationship 4 </label><label class="label-message" for="input_30"> e.g. Mother, Father, Friend </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_11"><div class="form-label-left" id="label_11"><label for="input_11"> Full Name 5 </label><label class="label-message" for="input_11"> </label></div><div id="cid_11" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q11_fullName11[first]" id="first_11" autocomplete="given-name" />  <label class="form-sub-label" for="first_11" id="sublabel_first">Civil Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q11_fullName11[middle]" id="middle_11" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_11" id="sublabel_middle">Jewish Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q11_fullName11[last]" id="last_11" autocomplete="family-name" />  <label class="form-sub-label" for="last_11" id="sublabel_last">Father's Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="4" name="q11_fullName11[suffix]" id="suffix_11" autocomplete="honorific-suffix" />  <label class="form-sub-label" for="suffix_11" id="sublabel_suffix">Last Name</label></span> </div></li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> Date of Passing 5 </label><label class="label-message" for="input_17"> </label></div><div id="cid_17" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_17" name="q17_input17[month]" type="tel" size="2" maxlength="2" value="08" />  <label class="form-sub-label" for="month_17" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_17" name="q17_input17[day]" type="tel" size="2" maxlength="2" value="31" />  <label class="form-sub-label" for="day_17" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_17" name="q17_input17[year]" type="tel" size="4" maxlength="4" value="2025" />  <label class="form-sub-label" for="year_17" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_17_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_17_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> Relationship 5 </label><label class="label-message" for="input_29"> e.g. Mother, Father, Friend </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_10"><div class="form-label-left" id="label_10"><label for="input_10"> Full Name 6 </label><label class="label-message" for="input_10"> </label></div><div id="cid_10" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q10_fullName10[first]" id="first_10" autocomplete="given-name" />  <label class="form-sub-label" for="first_10" id="sublabel_first">Civil Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q10_fullName10[middle]" id="middle_10" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_10" id="sublabel_middle">Jewish Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q10_fullName10[last]" id="last_10" autocomplete="family-name" />  <label class="form-sub-label" for="last_10" id="sublabel_last">Father's Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="4" name="q10_fullName10[suffix]" id="suffix_10" autocomplete="honorific-suffix" />  <label class="form-sub-label" for="suffix_10" id="sublabel_suffix">Last Name</label></span> </div></li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> Date of Passing 6 </label><label class="label-message" for="input_16"> </label></div><div id="cid_16" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_16" name="q16_input16[month]" type="tel" size="2" maxlength="2" value="08" />  <label class="form-sub-label" for="month_16" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_16" name="q16_input16[day]" type="tel" size="2" maxlength="2" value="31" />  <label class="form-sub-label" for="day_16" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_16" name="q16_input16[year]" type="tel" size="4" maxlength="4" value="2025" />  <label class="form-sub-label" for="year_16" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_16_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_16_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> Relationship 6 </label><label class="label-message" for="input_28"> e.g. Mother, Father, Friend </label></div><div id="cid_28" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_28" name="q28_input28" size="20" value="" /> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Full Name 7 </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q9_fullName9[first]" id="first_9" autocomplete="given-name" />  <label class="form-sub-label" for="first_9" id="sublabel_first">Civil Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q9_fullName9[middle]" id="middle_9" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_9" id="sublabel_middle">Jewish Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q9_fullName9[last]" id="last_9" autocomplete="family-name" />  <label class="form-sub-label" for="last_9" id="sublabel_last">Father's Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="4" name="q9_fullName9[suffix]" id="suffix_9" autocomplete="honorific-suffix" />  <label class="form-sub-label" for="suffix_9" id="sublabel_suffix">Last Name</label></span> </div></li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> Date of Passing 7 </label><label class="label-message" for="input_15"> </label></div><div id="cid_15" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_15" name="q15_input15[month]" type="tel" size="2" maxlength="2" value="08" />  <label class="form-sub-label" for="month_15" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_15" name="q15_input15[day]" type="tel" size="2" maxlength="2" value="31" />  <label class="form-sub-label" for="day_15" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_15" name="q15_input15[year]" type="tel" size="4" maxlength="4" value="2025" />  <label class="form-sub-label" for="year_15" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_15_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_15_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> Relationship 7 </label><label class="label-message" for="input_27"> e.g. Mother, Father, Friend </label></div><div id="cid_27" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_27" name="q27_input27" size="20" value="" /> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Full Name 8 </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q8_fullName8[first]" id="first_8" autocomplete="given-name" />  <label class="form-sub-label" for="first_8" id="sublabel_first">Civil Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q8_fullName8[middle]" id="middle_8" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_8" id="sublabel_middle">Jewish Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q8_fullName8[last]" id="last_8" autocomplete="family-name" />  <label class="form-sub-label" for="last_8" id="sublabel_last">Father's Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="4" name="q8_fullName8[suffix]" id="suffix_8" autocomplete="honorific-suffix" />  <label class="form-sub-label" for="suffix_8" id="sublabel_suffix">Last Name</label></span> </div></li><li class="form-line" id="id_24"><div class="form-label-left" id="label_24"><label for="input_24"> Date of Passing 8 </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_24" name="q24_input24[month]" type="tel" size="2" maxlength="2" value="08" />  <label class="form-sub-label" for="month_24" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_24" name="q24_input24[day]" type="tel" size="2" maxlength="2" value="31" />  <label class="form-sub-label" for="day_24" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_24" name="q24_input24[year]" type="tel" size="4" maxlength="4" value="2025" />  <label class="form-sub-label" for="year_24" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_24_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_24_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Relationship 8 </label><label class="label-message" for="input_26"> e.g. Mother, Father, Friend </label></div><div id="cid_26" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_26" name="q26_input26" size="20" value="" /> </div></li><li class="form-line" id="id_7"><div class="form-label-left" id="label_7"><label for="input_7"> Full Name 9 </label><label class="label-message" for="input_7"> </label></div><div id="cid_7" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q7_fullName7[first]" id="first_7" autocomplete="given-name" />  <label class="form-sub-label" for="first_7" id="sublabel_first">Civil Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q7_fullName7[middle]" id="middle_7" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_7" id="sublabel_middle">Jewish Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q7_fullName7[last]" id="last_7" autocomplete="family-name" />  <label class="form-sub-label" for="last_7" id="sublabel_last">Father's Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="4" name="q7_fullName7[suffix]" id="suffix_7" autocomplete="honorific-suffix" />  <label class="form-sub-label" for="suffix_7" id="sublabel_suffix">Last Name</label></span> </div></li><li class="form-line" id="id_23"><div class="form-label-left" id="label_23"><label for="input_23"> Date of Passing 9 </label><label class="label-message" for="input_23"> </label></div><div id="cid_23" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_23" name="q23_input23[month]" type="tel" size="2" maxlength="2" value="08" />  <label class="form-sub-label" for="month_23" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_23" name="q23_input23[day]" type="tel" size="2" maxlength="2" value="31" />  <label class="form-sub-label" for="day_23" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_23" name="q23_input23[year]" type="tel" size="4" maxlength="4" value="2025" />  <label class="form-sub-label" for="year_23" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_23_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_23_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> Relationship 9 </label><label class="label-message" for="input_25"> e.g. Mother, Father, Friend </label></div><div id="cid_25" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_25" name="q25_input25" size="20" value="" /> </div></li><li class="form-line" id="id_6"><div class="form-label-left" id="label_6"><label for="input_6"> Full Name 10 </label><label class="label-message" for="input_6"> </label></div><div id="cid_6" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q6_fullName6[first]" id="first_6" autocomplete="given-name" />  <label class="form-sub-label" for="first_6" id="sublabel_first">Civil Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q6_fullName6[middle]" id="middle_6" autocomplete="additional-name" />  <label class="form-sub-label" for="middle_6" id="sublabel_middle">Jewish Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q6_fullName6[last]" id="last_6" autocomplete="family-name" />  <label class="form-sub-label" for="last_6" id="sublabel_last">Father's Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="4" name="q6_fullName6[suffix]" id="suffix_6" autocomplete="honorific-suffix" />  <label class="form-sub-label" for="suffix_6" id="sublabel_suffix">Last Name</label></span> </div></li><li class="form-line" id="id_22"><div class="form-label-left" id="label_22"><label for="input_22"> Date of Passing 10 </label><label class="label-message" for="input_22"> </label></div><div id="cid_22" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_22" name="q22_input22[month]" type="tel" size="2" maxlength="2" value="08" />  <label class="form-sub-label" for="month_22" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_22" name="q22_input22[day]" type="tel" size="2" maxlength="2" value="31" />  <label class="form-sub-label" for="day_22" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_22" name="q22_input22[year]" type="tel" size="4" maxlength="4" value="2025" />  <label class="form-sub-label" for="year_22" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_22_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_22_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_33"><div class="form-label-left" id="label_33"><label for="input_33"> Relationship 10 </label><label class="label-message" for="input_33"> e.g. Mother, Father, Friend </label></div><div id="cid_33" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_33" name="q33_input33" size="20" value="" /> </div></li><li class="form-line" id="id_36"><div class="form-label-left" id="label_36"><label for="input_36"> Yahrtziet Reminer </label><label class="label-message" for="input_36"> </label></div><div id="cid_36" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_36_0" name="q36_input36[]" value="Yes! Please reminder before the proper Yahrtziet date" /><label id="label_input_36_0" for="input_36_0"><span>Yes! Please reminder before the proper Yahrtziet date</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_50" class="form-input-wide"> <div class="form-header-group"><h2 id="header_50" class="form-header">Payment</h2></div> </li><li class="form-line" id="id_39"><div class="form-label-left" id="label_39"><label for="input_39"> Total </label></div><div id="cid_39" class="form-input"> <div id="total_amount">$0.00 </div> </div></li><li class="form-line" id="id_42"><div class="form-label-left" id="label_42"><label for="input_42"> Payment </label><label class="label-message" for="input_42"> </label></div><div id="cid_42" 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_42_creditCard" name="q42_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_42_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_42_paypal" name="q42_payment[payment_method]" value="paypal" onclick="BuildSource.paypal(this)" /><label for="input_42_paypal">Paypal</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_42_other" name="q42_payment[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_42_other">Check</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="q42_payment[cc_type]" id="input_42_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="q42_payment[cc_number]" id="input_42_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_42_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="q42_payment[cc_ccv]" id="input_42_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_42_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="q42_payment[cc_nameOnCard]" id="input_42_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_42_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="q42_payment[cc_exp_month]" id="input_42_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_42_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="q42_payment[cc_exp_year]" id="input_42_cc_exp_year" autocomplete="cc-exp-year"><option></option><option value="2025">2025</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></select>  <label class="form-sub-label" for="input_42_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="other hide"><td colspan="2">Please make checks to: Chabad of the Delta 1062 Somersby Way, Brentwood CA 94513</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="q42_payment[addr_line1]" id="input_42_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_42_addr_line1" id="sublabel_42_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="q42_payment[city]" id="input_42_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_42_city" id="sublabel_42_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q42_payment[state]" id="input_42_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_42_state" id="sublabel_42_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="q42_payment[postal]" id="input_42_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_42_postal" id="sublabel_42_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q42_payment[country]" id="input_42_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 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