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Authorization for Interment

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The maximum number of form submissions has been reached. This form is currently not available.
- No interment shall take place until a written authority, signed by the proper relative or legal representative of the deceased, in addition to the plot deed has been given to the Cemetery. The undersigned hereby request and authorize.
- Name of Decedent REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Date of Death REQUIRED Please fill out this field. Please enter a date.
- Age Please enter an integer (number).
- Gender Please enter valid data.
- Veteran? Yes No
- Current Deed Owner Please enter valid data.
- If you are in need of a burial plot, please fill out our Plot Purchase form prior to submitting this form.
- Signatory Name: (if different from Current Deed owner) Please enter valid data.
- Signtatory Address Please enter valid data.
- Phone Number REQUIRED
  
  Please fill out this field. Please enter a phone number.
- Interment Space (Section: Row: Grave No.):
- Location of burial facing the headstone - left to right 1___ 2___ 3___ 4___ Please enter valid data.
- Original Deed Please select this field.
- Copy of Deed Please select this field.
- Funeral Home Please enter valid data.
- Funeral Home Address & Phone Number Please enter valid data.
- Funeral Director Please enter valid data.
- Date & Time of Funeral Please enter valid data.
- Place of Funeral Service (include Town) Please enter valid data.
- Pre-Existing Memorial: Yes No (if Yes, name currently on monument) Please enter valid data.
- Type of Service: Committal Yes No Please enter valid data.
- The undersigned hereby certify that they are the next of kin of the above named Decease, or otherwise have the full legal authority to direct the interment, or interment of the remains of the Deceased, and hereby authorize the above named cemetery to make disposition of the remains of the Deceased as indicated above. The undersigned hereby further certify and represent that they are the owner(s) or authorized representative(s) of the owner(s) of the above described Internment Rights and hereby authorize use of the said Interment Rights for the interment or inurnment of the remains of the Deceased. Cemetery is hereby authorized to install any outer burial container purchased in connection with this interment in the interment space described herein. The undersign hereby agree to indemnify and hold harmless the cemetery, its affiliates and their respective agents, officers and employees from any and all losses, cost of liability, including reasonable attorney's fees, it or any of them may sustain in connection with misrepresentations, misstatements, negligence, intentional acts or mosconduct by the undersigned as it relates to the interment or inurnment authorized hereunder. The undersigned agree that, at its own expense the cemetery has the right to correct an error in the interment or unurnment with no further liability to any other party.
  I Agree Please select this field.
- Date REQUIRED Please fill out this field. Please enter a date.
- Sign Here REQUIRED Please fill out this field. Please enter valid data.
- Remarks Please enter valid data.
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