Mierkey, HenryCemetery Call Work Sheet
Date: l a/ d l / OF
Funeral Home/ Monument Company:
Contact Name: 1 cc7' t- (
Tel. #: 5V I- Ltll&Lf
Reason for call:
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Deceased Name:
Date of Birth: Date of Death
Block Lot Space
Owner of Plot:
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Interment: (One full burial and one urn, or two urns per space)
Full Burial Urn Space
$30.00 Staking Fee - received on:
Date of Burial: Time: am/pm
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Disinterment:
The following authorization should be obtained prior to disinterment:
1.) A disinterment permit and burial/cremation transit permit
2.) Written authorization from the individual(s) who currently own the burial rights
for the plot; and
3.) Written authorization from the individual(s) who would be permitted to authorize burial
e r k
Fax #:
Monument Being Placed: (No Fee for Staking of Monument)