ILLINOIS POLICE MEMORIAL NOTIFICATION FORM NAME OF

ILLINOIS POLICE MEMORIAL NOTIFICATION FORM
NAME OF OFFICER: _________________________________________________________
(First)
(Middle)
(Last)
(Sr., Jr., III, etc.)
OFFICER RANK: __________________________ END OF WATCH: _________________
DEPARTMENT: _____________________________________________________________
DEPARTMENT LOCATION (CITY/TOWN):____________________________________
PROVIDE A BREIF DESCRIPTION OF THE INCIDENT:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
SUBMIT COPIES OF AVAILABLE DOCUMENTATION:
Examples:
1. Death Certificate and/or Autopsy Report
2. Coroner’s Report
3. Newspaper article(s) regarding the incident/death
4. Court Documents
5. Department Report
6. Statement of Circumstances (Department issued)
Mail or email this form and documentation to:
Illinois Police Officer Memorial (Criteria Committee)
840 S. Spring Street, P.O. Box 9347, Springfield, IL 62791-9347
[email protected]
Receipt of the Illinois Police Memorial Notification Form and supporting documents must be
received by the committee no later than December 31st in order to be considered for inclusion in
the May ceremony in Springfield.
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SUBMITTER’S CONTACT INFORMATION
Please provide your contact information. This will allow us to be able to contact you should we
have any follow up questions.
Your Name: __________________________________________________________________
Mailing Address: ______________________________________________________________
Daytime Phone Number: ________________________________________________________
Email Address: ________________________________________________________________
Your Relationship to the Officer: _________________________________________________
KNOWN FAMILY CONTACT INFORMATION
Providing any known family members will allow us to update them of the status of the case,
especially in the event that this officer will be included in the memorial.
Family Member Name: _________________________________________________________
Mailing Address: ______________________________________________________________
Daytime Phone Number: ________________________________________________________
Email Address: ________________________________________________________________
Relationship to the Officer: ______________________________________________________
Family Member Name: _________________________________________________________
Mailing Address: ______________________________________________________________
Daytime Phone Number: ________________________________________________________
Email Address: ________________________________________________________________
Relationship to the Officer: ______________________________________________________
Family Member Name: _________________________________________________________
Mailing Address: ______________________________________________________________
Daytime Phone Number: ________________________________________________________
Email Address: ________________________________________________________________
Relationship to the Officer: ______________________________________________________
The Illinois Police Officers Memorial Committee truly appreciates your submission of this form.
Feel free to contact us through mail or email if you have any questions or concerns.
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