Submit A Name - The Something Fishy Website on Eating Disorders

Memorial Wall :: ~~Submit A Name~~

Lighting A Candle for a Loved-One

I know it is incredible painful to lose someone you love and I do not wish to make the process any more difficult. The form below seems cold and impersonal and it is not intended that way... for the benefit of everyone we just need to ensure accuracy. Please know that each submission I attend to personally and with much sympathy in my heart for each of you out there that has lost a loved-one to this horrible disorder. -- Amy

We DO NOT accept submissions from those who are still alive but feel as though they may be dying, nor do we accept submissions regarding any person who is still alive. No matter have ill someone may be, there is always hope.

INFORMATION TO APPEAR "IN LOVING MEMORY"
PLEASE INCLUDE THE INFORMATION EXACTLY AS YOU WOULD LIKE IT TO APPEAR "IN LOVING MEMORY" -- BE SURE TO PROOF READ YOUR SUBMISSION BEFORE HITTING THE SUBMIT BUTTON.
In Loving Memory of: (required)
What you would like to say In Loving Memory of your loved-one:
OPTIONAL INFORMATION
PLEASE INCLUDE THIS INFORMATION IF YOU HAVE IT SELECT WHETHER YOU WANT IT TO APPEAR OR REMAIN CONFIDENTIAL.
Date of Birth: (include this info. if you can)	Yes, this should appear with my loved-one's name No, this should NOT appear with my loved-one's name
Date of Death: (include this info. if you can)	Yes, this should appear with my loved-one's name No, this should NOT appear with my loved-one's name
CONFIDENTIAL INFORMATION
PLEASE FILL OUT AS MUCH OF THE FOLLOWING INFORMATION AS POSSIBLE: YOUR NAME AND E-MAIL ADDRESS ARE REQUIRED. FULL NAME OF THE DECEASED, LOCATION OF DEATH AND SOCIAL SECURITY NUMBER INFORMATION IS FOR INTERNAL PURPOSES ONLY... THIS INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL. ALL INFORMATION BELOW WILL NOT APPEAR on "IN LOVING MEMORY"
Your Name: (required)	(required)
E-mail: (required)	(required)
Full Name of Deceased:	(required)
Your relationship to the Deceased:	(required)
Location where the person passed away:
Their Social Security Number:
AGREE and SIGN -- REQUIRED
Send It!	BY DIGITALLY SIGNING THIS FORM and CLICKING ON I AGREE, IN ACCORDANCE WITH ALL APPLICABLE STATE AND FEDERAL LAWS, YOU AGREE THAT THE INFORMATION SUBMITTED IN THIS FORM IS TRUE AND ACCURATE TO THE BEST OF YOUR KNOWLEDGE AND NOT INTENTIONALLY FALSIFIED IN ANY WAY. DIGITAL SIGNATURE (Your Name):

:: Memorial Wall :: ~~Submit A Name~~ ::

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