Request Form

Section 1 – Deceased Individual Information

Section 1 – Deceased Individual Information

First Name of the Deceased

Middle Name of the Deceased

Last Name of the Deceased

Date of Birth

Date of Death

Place of Death

Veteran Status (if applicable)

Section 2 – Burial Details

Section 2 – Burial Details

Requested Burial Date:

Requested Burial Time:

Type of Burial:

Casket

Cremation (urn burial)

Cremation (in-ground placement)

Funeral Home or Service Provider (if applicable):

Clergy or Officiant Name (if applicable):

Section 3 – Burial Plot Information

Section 3 – Burial Plot Information

Burial Plot Location (if pre-selected or known):

Is this burial plot already owned or pre-paid?

Yes – Pre-paid / Previously owned

No – Payment is required

Unsure

Name of Original Plot Owner (if different from deceased):

Approximate Date of Original Purchase (if known):

Section 4 – Requestor / Responsible Party Information

Section 4 – Requestor / Responsible Party Information

Full Name of Requestor:

Relationship to Deceased:

Mailing Address:

Phone Number:

Email Address:

Section 5 – Additional Notes or Special Requests

Section 5 – Additional Notes or Special Requests

Additional information, requests, or considerations:

Burial Request Form