Memorial Garden Brick Application

*** Please be advised: This is an application process. Only applications of deaths investigated as a violent criminal homicide and ruled as such by the medical examiner and law enforcement for prosecution will be approved ***

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This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Email(Required)

Your Birth Date(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

About your loved-one taken by violent crime

Loved One's Full Name(Required)

My loved-one’s date of birth (please write out 1-2 digit month, 1-2 digit day, and 4 digit year)(Required)

My loved-one is my ___________ (son, sister, friend, etc.)(Required)

I am my loved-one’s _____________________ (daughter, father, friend, etc.)(Required)

Specific Method of Violent Criminal Homicide (shooting, etc.)(Required)

Where did the homicide occur (city, state)?(Required)

When did the homicide occur? (please write out 1-2 digit month, 1-2 digit day, and 4 digit year)(Required)

Brick Engravement Details

*** Please note: All characters on each of the three lines will be in all CAPS ***

How do you want your loved one's name to appear on the brick?(Required)

Limited to 22 characters including spaces

Do you want to include any dates on the brick? (Please write out 1-2 digit month(s), 1-2 digit day(s), and four digit year(s) and separate two dates with a dash)

Limited to 22 characters including spaces

Do you want to add any special text or phrase on the brick?

Limited to 22 characters including spaces

If you have any questions, please contact us: 919-831-2857 or info@nc-van.org