COVID-19 Memorial Form | Chickasaw Nation

> Our Nation > Community > Chickasaw Nation Virtual Memorial > COVID-19 Memorial > COVID-19 Memorial Form

To submit information about a loved one for the COVID-19 Memorial page, please complete the form below. The submitted individual will be listed on the Memorial page.

If you have questions or need assistance, please contact special events at (580) 310-7969.

Citizen or Employee’s Name:

Date of Birth:

Date of Death:

The wishes of next of kin will be respected regarding inclusion in this memorial. Are you next of kin?:

Yes
No

Please state your relationship to the person lost to COVID-19.:

Please provide one photo, if you would like.:

Name of Person Submitting Information:

Phone number:

Email:

By clicking submit, I hereby grant the Chickasaw Nation permission to use the submitted information and photograph(s) in any and all of its publications and in any and all other media, whether now known or hereafter existing, controlled by the Chickasaw Nation, in perpetuity, and for other use by the tribe.