Home
Search
Add Name
Remember All
Contact
Help Me
FAQ
Add a Name
Use this form to submit a new name.
Do not use this form to search for a name
, go
here
instead.
To submit a name to be placed on the Suicide Memorial Wall, please fill out all information below.
You will receive an e-mail confirmation after the name has been approved and placed on the wall.
Note: Javascript must be enabled to use this form
Last Name
(Required)
First - Middle
Maiden Name
(Required)
No nicknames, please
Age at Death
(Required)
Birth date
(Required)
(use format "Day Month-name Year", as in "03 April 1984")
Death Date
(Required)
(use format "Day Month-name Year", as in "14 November 2003"
Home Location
(Required)
(City [optional], State or Province, Country)
The information requested below helps us validate your submittal, and is only available to the site administrators.
Your name
(First and last)
(Required)
(first and last)
Your email address
(Required)
(Confirmation message will be sent to this email address)
Your relationship to
this person
(Required)
You are this person's
How did you find the Suicide Memorial Wall web site?
Would you like to join one of our e-mail support groups? If yes, check the box and we will send an application to you for either Parents of Suicides (POS) or Friends and Families of Suicides (FFOS) groups.
Comments
Note: all information submitted becomes the property of the Suicide Memorial Wall web site and its owners and administrators. The information will be checked for accuracy and used for internal purposes only.
Inappropriate information or text will be edited or deleted. By clicking the Submit Name button, you agree to these and any other terms of use of this site.
