If there are two spouses with two separate last names. Include one spouse’s first name under the “first name” field and the first spouse’s last name followed by the second spouse’s first and last name in the “last name’ field.

Name *
Name
Address *
Address
Baby's Birthdate
Baby's Birthdate
Baby's Anniversary Date
Baby's Anniversary Date
Baby's Birthdate
Baby's Birthdate
Baby's Anniversary Date
Baby's Anniversary Date
Baby's Birthdate
Baby's Birthdate
Baby's Anniversary Date
Baby's Anniversary Date
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By filling out this form, you agree to allow Brief Encounters to share your baby name(s) and date(s) in “Our Children Remembered” section of our digital newsletter. Please note that our newsletter is now published online. If you prefer us not to share this information, please do not include your baby’s name(s)/date(s) on this form. Thank you.

For assistance with this form or to add more than three losses, please contact our database manager Megan Wright at 503-646-1335 or email at database@briefencounters.org