Create a Memorial

Honor your loved one by sharing their story.

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* 1. First Name

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* 2. Middle Name (Optional)

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* 3. Last Name (Optional)

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* 4. Date of Birth (Please use 01 if the day or month is unknown. The year is most important)

Date

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* 5. Date of Death (please use 01 if the exact date is unknown. The month and year are most important).

Date

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* 6. Age in years

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* 7. Please describe your loved one in 5 words or less.

Example: "Brother, Father, Heart of Gold."

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* 8. Tell us a little about your loved one through your eyes. You may want to share your favorite memory of them, what will you miss most about them or how you think they would like to be remembered (1,000 characters).

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* 9. Please submit a picture of your loved one to be featured on our page.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File
By submitting your stories and/or images, you agree to the below:

I hereby grant DC HEALTH, their affiliates, and their respective licensees, agents, successors, and assigns (collectively, the “Authorized Parties”), the right and permission to use, reproduce, publish, and distribute, in whole or in part, any and all images, photographs, videos, audio recordings, and/or any other media or materials submitted by me or featuring [insert your loved one’s name] (the “Materials”), in any form, format, or media, for any lawful purpose whatsoever, including without limitation, promotional and marketing materials, educational materials, and for display on the DC HEALTH website, social media accounts, and other digital and print media properties (the “Properties”). By providing DC HEALTH with this non-exclusive, worldwide and perpetual right, you do not cede or assign your copyright in the materials you submit.

I represent and warrant that I have the legal authority to grant the foregoing rights and that the Materials do not infringe any privacy rights, intellectual property rights, or other rights of any third party. I represent that the Materials are not unlawful, libelous, threatening, defamatory, obscene, or otherwise objectionable. I agree to indemnify and hold harmless the Authorized Parties from any and all claims, damages, liabilities, costs, and expenses, including reasonable attorneys’ fees, arising out of or in connection with the Authorized Parties’ use of the Materials.

I understand that I am not entitled to any compensation or other consideration for the Authorized Parties’ use of the Materials, and that the Authorized Parties may use or modify the Materials in any way they see fit, without further notice or consent from me. I acknowledge that the Authorized Parties have no obligation to use the Materials.

I agree to allow DC HEALTH to use my stories and/or images on its website, social media, and other materials.

By agreeing on the form, I acknowledge that I have read and understand this consent and release, and that I am voluntarily agreeing to its terms. If you have any questions or concerns, email us at kenan.zamore@dc.gov.

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* 10. Please enter your name here to agree:

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* 11. Enter your email (optional)

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* 12. What zip code or ward would you like associated with your memorial for our map?

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