Longworth-Pylee, ElizabethCemetery Call Work Sheet
• Date: 3 /cL/ a a
pang: V Lar J cL
Contact Name: Tel. #: Fax #:
Email:
Reason for call: S i- nn
** 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 Burial: / / Time: am/pm
• **
Monument (Marker) being placed - (No fee for staking of monument)
For:
Block Lot Space 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
;FOUND AS CURRENT OWNER OF BLOCK: 14
OWNER 1: NAOMI LONGWORTH
SPACE TYPE: FULL
DISINTERMENTS
LOT: 433 SPACE:00
;FOUND AS CURRENT OWNER OF BLOCK: 14 LOT: 435 SPACE: 00
[OWNER 1: NAOMI LONGWORTH
SPACE TYPE: FULL
3/21/2022
BLOCK: 14 LOT: 435 SPACE: 00
DECEASED NAME: NAOMI LONGWORTH
BORN: 4/24/1934 DIED: 7/25/2003 INTERRED: 8/2/2003 BURIAL TYPE: FULL
INTERMENT NOTES:
BLOCK: 14 LOT: 433 SPACE: 00
DECEASED NAME: ALBERT LONGWORTH, JR
BORN: 10/10/1935 DIED: 8/22/1997 INTERRED: 8/30/1997 BURIAL TYPE: FULL