Brewers and Sons• q
Date: ` /1 /3
•
•
Cemetery Call Work Sheet
Funeral Home / Monument Company: Qy
Contact Name:
L1C1� Tel. #: 311f '{9 S I Fax #:
Email:
Reason for call:
**
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:
Deceas Name:
Block ± Lot Space
Date of Birth: / /
Date of Burial:
**
/ /
Date of Death / /
Time: am/pm
onument (Marker) being placed - (No fee for staking of monument)
For: _D C2 h., tie V
Block 9 Lot r% &Space I Date: / / Time:
Affidavit (Burial Rights) Verifying Burial space
Other reason:
******* *************,**********************************************************************
Send email to P&R to stake the space
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: / /
**************************************************************************************************
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