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End of Life Planning

* Full Name

* Today's Date

* Birthdate

Person to contact at my death

Phone number of designated contact

Email address of designated contact

Secondary person to contact at my death

Phone number of secondary designated contact

Email of Secondary Contact

My Hebrew name is

I would like:

To be buried at a cemetery (specify location below)

A green burial at Moles Green Acres, Ferndale

Greenish burial in Beth Israel Cemetery

To be cremated (discuss with Rabbi)

... with ashes interred (specify location below)

... with ashes spread (specify location below)

aquamation (discuss with Rabbi)

terramation (discuss with Rabbi)

To donate my body to medical science. We would accept remains to be interred in Section 2 if needed.

Specify location

I would prefer my funeral held at

Beth Israel

Graveside

Funeral home

Specified in pre-arranged funeral plan

No funeral

Name of funeral home

Other -- If none of the above, please describe:

Gravesite

I have not purchased a site

I have purchased a site

Location of gravesite or family plot (please specify)

I would like the service to be

Public

Private

Any specific requests for the funeral/memorial service (music, readings, prayers)?

I would like the following Jewish traditional customs to take place

All wood casket

Other natural materials casket (ie willow, mushroom, etc)

burial shroud only

Tahara (Ritual washing and purification) by the Chevra Kadisha

Shiva

Shiva location

Shiva -- number of days

Shiva -- Dietary preferences

Other

I would prefer my headstone be

Flat

Upright

Slant

Pillow

No preference

Headstone decoration (describe)

Headstone inscription should read

I would like memorial gifts made to (please list)

I would prefer my obituary include the following details

Include a photo

Yes

Other wishes

* Sign and date

This form goes to the Rabbi and the CBI office where it will be stored. Please print out this form and keep it with your personal papers.

DO YOU HAVE AN ADVANCE CARE DIRECTIVE? If not, visit Honoring Choices Pacific Northwest (www.honoringchoicespnw.org) or Northwest Regional Council (www.nwrcwa.org). If you have questions or want more information, contact Geraldine Reitz at (360) 319-1942 or by email at [email protected]