Memorials Advisory Committee

2. Name*
3. Email Address*
5. Mailing Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
13. Name of Honoree *
15. Date of Honoree's Death*
    Date of Honoree's Death

    Honoree must have been deceased for at least 1 year, prior to application.

17. Applicant's Relationship *
    -- Select One --Family MemberExecutor/Executrix of Estate
19. Date of Appointment*
    Date of Appointment
20. Court Appointment Documentation*
22. Please describe the contribution of the Honoree to our community*
24. Type of Memorial*
    -- Select One --BenchPlaquePublic PropertyOther
26. Other, Please Explain
28. Publicly Owned Property to be named

    Please provide the Publicly Owned Property to be Named and Location

    Applicants may request that the town name the following for an honoree: a wall of a town-owned building, rooms within a town-owned building, a pre-existing bench, playgrounds, future street signs.

30. Estimated Cost of Memorial*
31. Estimated Future Maintenance Costs*
32. Source of Funding *
34. Additional Supporting Documentation(Optional)
36. Disclaimer*

    1. I Agree to the following

    I have read, understand, and accept the guidelines of the Memorials Advisory Committee. 

    I understand that future maintenance is the sole responsibility of those funding this memorial. 

    I understand that failure to properly maintain the memorial may result in its removal by Town staff. 

    I understand that I will remain the point of contact for this memorial until and unless I notify the Memorials Advisory Committee of a change in responsibility

Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

* indicates a required field