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Cycadia Monument410 Date: O / 3 Funeral Home / Monument Company: asv,_,cyburP Cemetery Call Work Sheet CaucC2-t'c, Contact Name: i CC --Th Tel. #: Fax #: Email: -T.4,4V vYl �'�1 �'e (c y i CX9`lm t.k.k # 4 -_ Reason for call: ** Staking Request — Interment $30.00 staking fee (Weekdays) - $50.00 staking fee (Saturday, Sunday & Legal Holiday) ,IN Full Burial Urn Burial 1� (One full burial and o ` PA.,4 ne urn, or two urns per space) Owner of Plot: Deceased Name: ey.f; Block Lot Space/N Date of Birth: / / Date of Death / G'/ , Date of Burial: / / Time: am/pm )-).��i�( 1111 Monument (Marker) being placed - (No fee for staking of monumen pI For: ��cJ', 0 Block Lot Space Date: / / ime: v Affidavit (Burial Rights) Verifying Burial space Other reason: • **** **********, ,*****, *********************, *****, *******,************************************ Send email to PSBR 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 • 80149 148 I 47 451 5256 3 145 144143 421 41 3I 32 33 34 IS 37 38 39 40 30 29 28 27 7 24 23 22 21 11 12 13 14 IS 16 17 18 19 20 10 9 8 7 6 5 4 3 2 I 111 112 113 114 IIS 116 117 118 119 120 110 109 1061107 106 105 104 103 102 101 91 92 93 94 95 96 97 98 99 100 90 89 86 87 86 85 84 63 82 81 71 72 73 74 55 77 78 79 80 70 69 68 67 47 64 63 82 61 51 52 53 54 55 56 57 58 59 60 50 49 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 39 401 30 29 28 27 26 25 24 23 22 21 J 20] 567 568 589 570 571 572 573 574 575 576 566 565 564 563 562 561 560 559 558 557 547 548 549 550® 531 553 554 555 556 546 54,65 523 543 4 540 539 538 537 527 528 529 530 531 532 521 533 520 5341535 536 519 15I815i7 526 525 524 523 522 507 506 508 505 509 504 SIO 503 5V 502 512 501 SE E SHEET 3 513 500 YRTE. R.. 95 96 94 93. St 62 {o 79 65 66 64 119 49 So / 26 27 28 29 30 [21 31 32 33 34 I 25 1 24 23 � 22 1 20 19.4 18, 17 p2 [ 45 1 26 1.21 4 41 28 29 30 31 32 33 34 35 36 27 26 25 24 3 2 21 20 19 10 11 12 13 16 17 18 9 8 7 6 5 4 3 2 I 96 94 49 149 25 24 I i 961195 1 74 172 1 50 4 7 l 26 23 1 2 99 94 75 70 51 46 27 22 3 1 100 9393 l 76 169 l p2 [ 45 1 26 1.21 4 101 9 17 86a130(2920 102 921 T8 67 19I6 103 90 79 66 55 42 31 18 7 104 69 60 65 56 41 2 17 8 105 88 81 64 57 40 33 16 9 106 87 82 63 58 39 34 15 10 107 l 8 83 62 59 38 35 14 l 11 l{85 84 61 60 37 36 13 1 771176 155 154 133 132 111 110 178 175 156 153 134 131 112 109 90 179 174 157 152 135 130 113 108 91 18011731 1.58 1151 136 129 114 107 921 181 172 159 150 137 128 115 106 93 182 171 160 149 138 127 116 105 94 183 170 161 148 139 126 117 104 95' 1164 169 162 168 1631146 } 1411 124 119 102 147 140 125 118 103 '!Sb6) 7 19'7 96 97 351 36 137 1 I6 IS 14 13 l2� 110 9 8 7 6 5 4 3 2 1 24 23 22 39 34 19 18 17 9 10 II a 14 15 16 8 1 6 5 4 3 2 I 73 72 49 48 25 24 95 174 71 50 47 26 23 2 92 77 68 91 78 67 0.12390 jis1 6 I 81 f 57 140 I 33 16 l I 186 67, 82 16463 58 39 34 15 0 86 83 62 59 38 35 14 II (84 61 60 37 36 13 (8 67 66 45 44 23 22 87 68 65 46 43 24 21 2 86 69 64 47 42 25 20 3 [85 I TO 84 71 63 14.8 141 126 1 19 1 62 89 40 27 18 S 83 72 61 50 39 28 I7 6 82 73 60 51 38 29 16 7 81 74 59 52 37 30 15 8 80 75 58 53 36 31 14 9 ! " !1/67'1 faiife30 [79 76 1 S7, 54 .35 T32 ! / ,4q 1�3El 1l�1 /s l �� 178 17.3.156 55.134 133 13 I0 12 11 AVE NUF 86 75 70 59 34 74 73 71 72 56 57. 55 56 28 43 36 27 22 6 42 39 26 23 10 7 41 40 25 24 9 6 23 22 13 12 35 pt 27 36 31 26 37 30 29 7 6 24 1 is 19--,1. 17 14 23 Is 22 It it V21 20 II 19 is 25 7 { 1 { 6. L{ ! I7 9 2 10 • 5 a 20 15 21 14 22 13 23 12 r----71 I I I 19 Ick 4 1.111 .L4 I u 14 3 • 47 16 9 t I 1 I 16 I IS I 6 I 5 14 7 4 NI' 8 3 90 2 10 12 19 22 23 14 24 13 16 I IS 17 14 18 13 11 12 3 2 0 F S 23 10 26 9 27 E 28 7 7 I 4 0 8 19 12 9 122 23 3 C 2 6 28 A 29 26 27 30 29 30 S 31 4 52 33 2 34 d1,IMV 1 nl