Memorial Plaque Application

Memorial Request Application

The intent of the Town of Riverhead is to allow the placement of privately donated memorials in town parks/beaches to honor the memory of a former resident of the town. This memorial application shall be limited to approved memorial items and locations.

Applicant's Information

* Indicates required field

Applicant Name: *

Applicant Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

The Memorialized's Information

Name of Memorialized *

First

Last

Type of Memorial (Bench, Plaque, Rock, etc) *

Location of Memorial *

Last Known Town of Riverhead Address *

Line 1

Line 2

City

State

Zip Code

Country

Detailed Description (full details of memorial, including text on any plaque, size of bench/rock,etc) *

As the applicant, I hereby certify that the information I have provided on the form is complete and accurate to the best of my knowledge. I understand that this application is subject to approval by the Town of Riverhead and I shall not place any memorial items on Town of Riverhead property without approval.

Signature (Please Type Name) *

Date: *

Submit