Mae, Edith (Mai)0 Cemetery Call Work Sheet
Date: f-/ ()/ Ds
Funeral Home/ Monument Company: Gfficu, a. N Ott MW lid - _
Contact Name: l MN
Tel. #: 1% - 15E51 Fax #: ISS'
Reason for call: _ VOVIUSY0 40,6A RWU-QZ-L
Deceased Name:( I`?'{rl Mai C?c??
Date of Birth: Date of Death
• Block y , Lot I Space IL, ` 'q S C'?= L0WkFOO bttI k
Owner bLujes ,,I (Ja,??.2aw Iet?
of Plot: Teow[M>
Interment: (One full burial and one urn, or two urns per space)
Full Burial 1- Urn Space
$30.00 Staking Fee - received on: -1-1
Date of Burial: Time: am/pm
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
0 Monument Being Placed: --- (No Fee for Staking of Monument)