Heaney, John JDate: 10 / I I / do I 1
Monument Company: IQ 10 I—e-
ll ob Gr4 Ct Tel. tY40 -3 °55- Fax #:
Staking Request (Interment/Disinterment)
Affidavit (Burial Rights)
Monument (Marker) being placed
For: Jokii. J +6a "7
Block 4k Lot 31- Space
Date: i° / d °/ a° /7 Time:
(Send email to P &R)
Verifying Burial space
Other reason:
Funeral Home /
Contact Name:
Reason for call:
Cemetery Call Work Sheet
(No fee for staking of monument)
o4��7 513k ce_
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Interment: (One full burial and one urn, or two urns per space)
Full Burial
Owner of Plot:
Deceased Name:
Urn Space
Block Lot Space
Date of Birth: / / Date of Death / /
Date of Burial: / / Time: am /pm
$30.00 Staking Fee (Funeral Home) — received on: / /
Copy of permit emailed to Mark Tokar, cc: Cherise Sarnoff /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
Revised 11/24/14