EmailMeForm
In 1994, the National Coalition Against Domestic Violence, in conjunction with Ms. Magazine started the Remember My Name™ project. This project was developed to create a national registry of victims who have lost their lives to domestic violence and to increase public awareness about domestic violence. Thirty years later, the National Domestic Violence Hotline (The Hotline) continues to honor this legacy by collecting names and information submitted by family and friends. If you would like to submit a name and information for inclusion in the registry, please complete this form.
Please note: Names and information about victims are preserved and maintained in our registry.
You may attach additional information such as news articles, police reports, court records, etc. Items submitted are no longer confidential and cannot be returned.
Due to the large number of submissions we receive, we ask that you restrict your submission to this form only.
An asterisk (*) indicates a required field.
Victim's First Name
*
Victim's Middle Name or Initial (no period please)
Victim's Last Name
*
Was the victim pregnant at the time of
their death?
*
Yes
No
How old was the victim at the time of their death?
Victim's Date of Death
*
MM
/
DD
/
YYYY
City in which the victim was killed:
*
State in which the victim died:
*
Please select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
D.C.
Perpetrator's first and last name:
*
First
Last
Perpetrator's age at the time
of the murder?
Perpetrator's relationship to the victim?
*
please use one or two words
What weapon did the perpetrator use to kill the victim?
*
please use only a few words
What was the cause of the victim's death?
*
please use only a few words
Did the perpetrator survive?
*
Yes
No, committed suicide at time of murder
No, killed by law enforcement during incident
No, other (please specify)
If the perpetrator survived, what charges were filed (if any)?
Is the case still pending?
*
Yes
No
Perpetrator sentence (if known):
Were there other victims?
*
Yes
No
Please list the names, ages, relationship to primary victim and weapon used of any additional victims below:
Additional victim #1 name
First
Last
Additional victim age
Relationship to victim
Weapon used
Additional victim #2 name
First
Last
Additional victim age
Relationship to victim
Weapon used
Additional victim #3 name
First
Last
Additional victim age
Relationship to victim
Weapon used
Additional victim #4 name
First
Last
Additional victim age
Relationship to victim
Weapon used
Were there witness(es) to the murder?
*
Yes
No
Number of surviving children of the victim, if any:
Please check any that apply:
*
Custody issues
Record of prior abuse
Prior shelter contact
Drugs/Alcohol
Prior police contact
Restraining/Protection Order
None
Relationship Status:
Married
Divorced
Separated
Dating
Other
Additional comments:
Please list the source(s) of information (links to websites) where we can find news stories or more information about this case:
Please include the EXACT links to online news stories about this case. If you do not know how to copy and paste hyperlinks, please upload any news articles below (limit--3).
The Hotline is sometimes asked to share pictures and information about those included in this project for various reasons, including legislative and other activist/advocacy activities. Do you give The Hotline permission to share your loved one's information for these purposes? *
Yes, I/we give permission
No, I/we do not give permission
Please use this option ONLY if you do not know how to copy and paste hyperlinks as listed above.
Add File
Please do not send case documents. News articles only please (limit--3). Thank you.
Please list your name:
*
First
Last
Your relatonship to victim
Your email address:
