Day of Remembrance Registration Form

overdose awareness day

Erie County Department of Health (ECDOH) Office of Harm Reduction

The opioid overdose epidemic has taken a heartbreaking toll on our community, claiming the lives of far too many.

Event Details:

Thursday, August 31, 2023

Old County Hall, 92 Franklin St. Buffalo, NY 14202

10:00 am - 6:00 pm: Memorial displays will be set up on the lawn

6:00 pm: Remembrance event

If you would like to honor your loved one that has been taken by this opioid epidemic, please fill out the information below that you would like displayed in upcoming memorial events. You may also upload a photo of your loved one if you wish to.

Your First Name

Your Last Name

Your Loved one's First Name

Your Loved one's Last Name

Your Phone Number

Your Loved One's Date of Birth (Optional)

Your Loved One's Date of Passing (Optional)

Would you like to upload a photo of your loved one?

Yes

Please upload a photo of your loved one. File types accepted include gif, jpg, jpeg, png, pdf

One file only.
2 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf.

Electronic signature and photo release agreement

By checking this box, I acknowledge that:

I grant the Erie County Department of Health, its representatives and employees the right to use my loved one's name and/or this photograph of my loved one in connection with the above-identified subject. I authorize the Erie County Department of Health, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that the Erie County Department of Health may use such photographs of my loved one with or without their name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content.

Would you like to be notified by email of the Erie County Opiate Task Force Meetings?

Yes

Your Email

Confirm Your Email