Request to Add a Name on
"Children, Sibling or Friends Remembered"

I would like to have the name of the following deceased child/sibling

listed on the Internet on the "Our Children Remembered"page.

Enter the name as you would like it to appear

Date of Birth
Date of Death
Favorite Color
Favorite Song
Favorite thing
Favorite song 2
Death caused by

My child's name can appear on:
The web site
Name Only "web site"

My Sibling's name can appear on

The web site
Name Only "web site"

My Friend's name can appear on

The web site
Name Only "web site"

I have permission of my friends parents to add them

Please enter their relationship to you
(Son, Daughter, Brother, Sister)

Please enter your information below

First and Last Name

Address,City, State & Zip

Phone Number
Email Address

If you have a Memorial Page that you would like to have
linked to the name, please enter the URL (page address).
Comments or Questions

Some will contact you
Because the Internet is open to the public, you must agree to the following in order to have your child's name, picture or
anything else that is to be added to their personal page to appear on the web site.
By clicking the submit button on this request form you are releasing
& the webmaster from any and all liability of any use that may become of the name by others who see it.

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