9/11 Living Memorial Submission Form

This form should be used to create a page by the families of a survivor or responder who died from 9/11-related illnesses. Additionally, victims’ families can contribute to their loved one’s page for the first time, or to add to their existing memorial page. Up to ten images may be contributed for each submission.

If you have questions or need help with the upload process, contact Stephanie Landau at slandau@voicescenter.org or call 203.966.3911
Your Information

Please provide your contact information as accurately as possible.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Relationship to Victim*
Are you the legal next of kin?*

YesNo
Best time to reach by phone
Questions or Comments?

Victim Information

Please provide the information of the victim below as accurately as possible.
Victim Participation:

World Trade Center Health ProgramSept 11 Victim Compensation FundNY State Workers CompensationWTC Health Registry9/11 Museum RegistryOther
Name Displayed as:*
This would the title of the page
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Nickname
Victim Group*
Gender
Age When Deceased
Work Organization
Work Title
Address When Deceased

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Personal Website
Interests
Separate by comma
School/Education
Separate by comma
Foundation(s)
Separate by comma
Biography
Provide an account of the deceased person's life.
Obituary
Text of notice of a death, including a brief biography of the deceased person.

Portrait Photo

Each Living Memorial Remembrance Page has a single primary portrait photo to represent the deceased. Use the uploader below to submit a photo.

How to Upload an Image

Click the "Select image" button

Choose the single image you'd like to upload

A preview image will appear

If the correct image shows, click the upload icon
Upload Portrait Photo:
Remembrance Photos

In the image upload fields below, you have the option to upload up to 10 images for Living Memorial Remembrances. Each uploader is a field for captions, which is a brief description accompanying the photo.

How to Upload Images

Click the "Select image" button

Choose the single image you'd like to upload

A preview image will appear

If the correct image shows, click the upload icon

Up to 10 images may be submitted in total
Accepted file types: png gif jpg jpeg
2 MB size limit for each photo
Upload Remembrance Photo (1 of 10):
Caption (1 of 10):
Upload Remembrance Photo (2 of 10):
Caption (2 of 10):
Upload Remembrance Photo (3 of 10):
Caption (3 of 10):
Upload Remembrance Photo (4 of 10):
Caption (4 of 10):
Upload Remembrance Photo (5 of 10):
Caption (5 of 10):
Upload Remembrance Photo (6 of 10):
Caption (6 of 10):
Upload Remembrance Photo (7 of 10):
Caption (7 of 10):
Upload Remembrance Photo (8 of 10):
Caption (8 of 10):
Upload Remembrance Photo (9 of 10):
Caption (9 of 10):
Upload Remembrance Photo (10 of 10):
Caption (10 of 10):
Terms and Conditions*
Should be Empty: