Monument Paver Donation Form

A Lasting Memorial to the Coal Miner Most Important to You

PLEASE NOTE: THIS FORM IS NOT FOR LISTING A COAL MINER WHO WAS KILLED ON-THE-JOB. There is a separate form found under the appropriate link. Listing the name of a coal miner who was killed on-the-job is at no cost as long as the coal miner was a resident of Pike County or worked in a Pike County coal mine.


An opportunity for you to have a lasting tribute to that coal miner who is most important to you. Please click on the link below and download the form with the needed information.

This will ensure that your coal miner's name and occupation will be a permanent part of the Pike County Coal Miner Monument/Memorial. Your donation of $150.00 will fund the monument and a lasting tribute to your coal miner. Submitting incomplete form information will delay or could prevent completion of your request.


Download and complete this form and return to us at Pike County Coal Miner Memorial Fund, Inc., 237 2nd Street, Suite 5, Pikeville, KY 41501. Donations are tax deductible.