Required fields are marked with asterisks (*)

Memorial Request

Please complete and submit the following request for a memorial. Review of requests and installation of memorials will be performed in accordance with the Town of LaSalle's Memorial Program Policy.

First Name

Last Name

Street Address

Unit Number

City

Postal Code

Primary Phone Number

Email Address

Please select the type of Memorial you would like to request.

Memorial Bench

Memorial Brick

Memorial Tree

Privacy Statement: Personal information collected on this form is collected pursuant to Town of LaSalle policies and applicable bylaws. Information will be used for processing Memorial Requests. Questions about the collection of this information should be directed to the Director of council Services/Clerk, and can be reached at 519-969-7770 ext. 1223.