Smith, MikeCemetery Call Work Sheet
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Funeral Home/ Monument Company:
Contact Name:
Tel. #: CXjj . Lf 5 9 - to 3 `f
Fax #:
Reason for call: Staking Request (Interment)
Affidavit (Burial Rights)
Monument (Marker) being placed
(No fee for staking of monument)
Other reason: grave L0C_c.Jl 1e1ty Zv?o . (3kL f) Lo-f '2.?,
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Interment: (One full burial and one um, or two urns per space) AJ ? ise I Kr
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40 ull Burial Urn Space
Owner of Plot:
Deceased Name:
Block Lot Space
Date of Birth:
Date of Burial:
Time
am/pm
$30.00 Staking Fee (Funeral Home) - received on: -/-/.
Copy of permit faxed to Joe Taylor/P&R - Fax No. 6551 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
Date of Death