Memorial Garden Brick Application

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)

Type 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

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

Comments

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

If you have any questions, please contact Dianna, NCVAN Memorial Garden Coordinator, at 919-831-2857 x 106 or dianna@nc-van.org.