Blackburn, Daniel WebsterCemeterv Call Work Sheet
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Date: 1a l l to l ao J o
Funeral Home / Monument Company:
-T gs &;n b? C4...e J S4c- ks,,?? A? FL
Contact Name: ? ? 3aa3kf
Tel. #: Rd?? £ 3 $ - 2-`f ga-- -Fax-#: ?
Reason for pall
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Deceased Name: .)a.?. id l,t AS-'nom- _ 6ra,l fem . -
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Date of Birth: (/ / 89S I I 3 J `t
Date of Death
Block s Lot Space _j_ ??uQQ ea..;.) 11"3°l31
Owner of Plot: (,U, kr,o 0 ?h
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
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
Monument Being Placed: (No Fee for Staking of Monument)
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