Headstone Application — Remembering Those We Lost

Who may apply: A family member, legal guardian, or authorized advocate of a victim of violent crime who does not have a permanent headstone. Applications are reviewed with care and compassion. Please read the eligibility requirements sheet before filling out.

Section 1 — Applicant Information

First Name *

Last Name *

Relationship to Deceased *

Phone Number *

Email Address

Best Time to Contact

Mailing Address (Street, City, State, ZIP)

Section 2 — Information About the Deceased

Full Legal Name *

Nickname / Known As

Date of Birth

Date of Passing *

Age at Time of Passing

City & State Where Passing Occurred

Manner of Death (violent crime)

Section 3 — Cemetery / Burial Information

Cemetery Name *

Cemetery City & State *

Section / Lot / Block / Grave # (if known)

Cemetery Phone (if known)

Section 4 — Additional Information

Please share anything else about your loved one or your situation that would help us serve your family

How did you hear about Remembering Those We Lost?

Section 5 — Certification & Signature

I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that this application does not guarantee a headstone will be provided, and that all decisions are made at the sole discretion of Remembering Those We Lost. I give permission for the organization to contact the cemetery on my behalf.

Signature *

Date *

Printed Name *