Share Your Memorial Tribute

Have you lost a loved one to heroin? Please share your story below. Memorials give families and friends the chance to remember the lives of loved ones lost to substance abuse. Together our stories will increase awareness about the risks of using heroin. Please help us reach as many people as possible.  Below is an actual video we produced from pictures that were shared with us here.

Heroin Support Memorial
  1. IMPORTANT NOTICE: All fields below with an (*) next to them are REQUIRED to be filled out before you can submit your tribute.

  2. Your First Name(*)
    Required: Please include the applicant's first name.
  3. Your Last Name(*)
    Required: Please include the applicant's last name.
  4. Your Relationship to Deceased(*)
    Required: Your Relationship to Deceased
  5. Your Email(*)
    Required: Invalid email address.
  6. Do you want us to include your name in the tribute? (*)
    Invalid Input
  7. First Name of Deceased(*)
    Required: include first name of deceased.
  8. Last Name of Deceased(*)
    Required: include last name of deceased.
  9. Birth Date(*)
    Required: Birth Date
  10. Date of Passing(*)

    Required: include the date of passing
  11. Age of Deceased(*)
    Required: Age of Deceased
  12. state(*)
    Required: include state of deceased.
  13. Zip Code(*)
    Required: include deceased zip code.
  14. Choose at least one picture to upload of the deceased person.

  15. 1st Picture(*)
    Required: At least one picture
  16. Optional 2nd Picture
    Invalid Picture:
  17. Share some thoughts about them.

  18. Tell us about them(*)
    Required: Tell us about them
  19. Tell us about their struggle with addiction.(*)
    Required: tell us about their struggle with addiction
  20. What made them smile?(*)
    Required: What made them smile?
  21. What do you miss the most about him/her?(*)
    Required: What do you miss the most about them?
  22. If you had a chance to say one more thing to your angel what would it be?(*)
    Required: Chance To Say One More Thing To Your Loved One
  23. Authorization Request

  24. Please check below to authorize Heroin Support Inc to use this data. I authorize you to share publicly all information submitted. I give my permission to use our names, photos, and communications as deemed necessary by Heroin Support Inc to advance their cause. This includes but is not limited to electronic, hard copy or video. All submissions, if used by Heroin Support Inc, become the property of Heroin Support Inc and require reprint permission from Heroin Support Inc. Users are solely responsible for anything contained in their submissions. Heroin Support, Inc. does not verify, endorse or otherwise vouch for the contents of any submission or comment. Users may be held legally liable for the contents of their submissions or comments, and may be held legally liable if their submissions or comments include, for example, material protected by copyright, trademark, patent or trade secret law or other proprietary right without permission of the author or owner, or defamatory comments
  25. Authorization to use this information.(*)
    Invalid Input
  26. Your Are Required To Click The Check Box Below.

  27. Please click the "I'm Not a Robot" box below so we know you are not a spammer. This box needs to have a check mark in it before you can submit your tribute.
    Required: You must click the "I'm not a robot" check box above.