Memorial Garden Brick Application

Name

First Last

Your Birth Date

Address

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

Phone

About your loved-one taken by violent crime

Loved One's Full Name

I am my loved-one's ___________ (daughter, father, friend, etc.)

Type of Violent Criminal Homicide (shooting, etc.)

Where did the homicide occur (city, state)?

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

Brick Engravement Details

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

Limited to 20 characters including spaces

Do you want to include on the brick your loved one's date of birth and date of homicide? (please write out 1-2 digit month, 1-2 digit day, 4 digit year

Limited to 20 characters including spaces

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

Limited to 20 characters including spaces

Phone

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.