EMS Memorial Nomination - Cover Sheet & Instructions

This is the Nomination Package for the NYS EMS Memorial. The Service is held during EMS Week each year. All nominations for any given Service must be received on or before December 1. Any nomination received after this date will be considered for the following year's Memorial.

Please TYPE OR CLEARLY PRINT all information. The Nomination Form contains two pages with four sections.

Nominee Information Narratives

Nominator Information Media Information

It's important that the individual(s) making this nomination complete all, or as much of this form as possible. If necessary contact nominee's family to verify personal information, ie. appropriate name to be used on memorial. Missing data will delay the processing of the nomination and could delay the nominee's inclusion in the Service for a full year.

It is also important that the nominee meets all of the following criteria:

  • Emergency Medical Service (EMS) nominees must have been a member of an authorized New York State EMS ambulance, ALS first response or BLS first response service. An authorized EMS service is an EMS service recognized by the Bureau of EMS. EMS services that are no longer active will also qualify if the line of duty death occurred when the service was active and authorized.
  • A Nominee must have died in the line of duty. Line of duty is defined as occurring during response to an emergency or non-emergency call, or on stand-by with an authorized EMS service, including traveling from home to the call or EMS station, and returning home or to the EMS stations from the call. Line of duty death can also be defined as a death resulting from illness or injury sustained while responding to a call.
  • A Nominee must have followed established laws, regulations, policies, protocols and generally accepted safety standards to be eligible.
  • An application form must be completed, signed and notarized by an officer of the EMS service in which the Nominee was a member. The application will contain a brief narrative describing how the line of duty death occurred, date and location. Applications must be postmarked by December 1st to be considered for the following year's service. A copy of the Nominee's obituary or death certificate must be submitted with the application.
  • If a nomination is not accepted, the EMS service submitting the nomination may appeal the decision in writing to the NYS EMS Council who will review the nomination and make a final decision.

The following items should be returned to the NYS EMS Memorial Committee on or before December 1:

  • The completed Nomination Form
  • Clearly legible copies of any newspaper articles relating to the line of duty death
  • Clearly legible copies of any published obituaries (if available).
  • Copies of any other documentation supporting this nomination.

Please return these items to:

NYS EMS Memorial Committee
New York State Department of Health
Bureau of Emergency Medical Services
875 Central Avenue
Albany, NY 12206

Questions on the nomination process should be directed to the NYS EMS Memorial Committee at: (518) 402-0996