CANADIAN VIRTUAL WAR MEMORIAL

Submitting the Electronic Form.

Please complete the following form and only submit digital photos with .gif, .jpg or .jpeg extensions. See guidelines for more information.

Deceased: SAMUEL ADAMS

Date of Death: October 8, 1916

Service Number: 63065

Rank: Private

Regiment: Canadian Infantry (Central Ontario Regiment)

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Donor Surname: *

Donor Given Name(s): *

Street Address:

City (or town):

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E-mail address: *

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Digital File: *

Donor's relation to deceased: *

Image Caption: *

I, (full name) * grant, and warrant that I am authorised to grant, Veterans Affairs Canada permission to reproduce and display the attached files on the Canadian Virtual War Memorial website. The reproduction and display of files submitted are entirely within the discretion of Veterans Affairs Canada.