Hubbard, Cora•
Cemetery CaII Work Sheet
Date: (0 /
Funeral Home / Monument Company: if1)c
Contact Name: wit cg Tel. #4
Email:
Reason for call:
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Staking Request — Interment
$30.00 staking fee (Weekdays) - $50.00 staking fee (Saturday, Sunday & Legal Holiday)
Full Burial Urn Burial
(One full burial and one urn, or two urns per space)
Owner of Plot:
Deceased Name:
Block '- Lot Space
Date of Birth: / / Date of Death / /
Date of Buria / / Time: am/pm
• **
•
Monument (Marker being placed o fee for staking of monument)
For: Cry �'�-(•�O
Block Lot e)(-{ Space P5 Date: / / Time:
Affidavit (Burial Rights) Verifying Burial space
Other reason: � �— Q .�
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Send email to P&R to stake the space (0:1
Notify funeral home/monument company with color of the flags used to mark the space
Staking fee received on: / / From:
Copy of permit emailed to:
Nathan Brigman, cc: Matt Anderson, Tim Chaplinsky, Erick Peterson in P&R on: / /
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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
ORLS/Cemetery/FormsPermitsTemplates/Cemetery Call Work Sheet -20
Revised 4/21/2021