Living Tribute Request – CT Nurses Honor Guard

The Connecticut Nurse Honor Guard considers it a privilege to honor our colleagues. Please provide us with the following information to request a tribute from the CT Nurses Honor Guard. We will do our best to honor each request. A member from the CT Honor Guard will confirm your request.

Name of person requesting living tribute

Contact Number

Address of family member requesting tribute

Are you the:

If Family, Relationship to Honoree?

If not a family member, is family aware of the request?

Name of nurse being honored with a living tribute

Phonetic pronunciation of name

Age

Date requested for Living Tribute

Time requested for Living Tribute

Alternate Date requested for Living Tribute

Alternate Time you would like tribute read:

To whom shall the lamp be given to after tribute:

Where you would like the tribute read

If Other, where

Address of Where the Living Tribute Will Be Read?

Do you give up permission to add your loved one's name and picture to our Honor Wall on our website?

Loved One's Photo

Do you give us permission to put your loved one's name on the Honor Wall on our Facebook page?