Hill, Jim
Cemetery Call Work Sheet
a.o II
Date. 3 / /
Funeral Home/ Monument Company:
Contact Name: -j" j. pU&at)
Tel. #:
CJ
36a- y7.3- 7553 Fax #:
Reason for call: f? e- ?? h n /tA i
Deceased Name: AKP, ST. 14 -- 02e."
Date of Birth: Date of Death / /
Block 16 Lot ( ?, Space Lt- (.A) Sra"- 3 = Seven ? . ? i _ CC(rk )
Owner of Plot: Atin?
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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
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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