CCS NEW Interment authorization 2016
Name of Decedent
Date of Birth
Month, Day of Signing Auth.
Year of Signing Auth. (20__)
Date of Death
Cemetery Section
Cemetery Lot
Cemetery grave space
Type of outer burial container
Supplier of outer burial container
Pleasant Grove Memorial Park
Type option 1
Murdale Gardens of Memory
Type option 1
Egyptian Memorial Gardens
Type option 1
Funeral date
Funeral Time
Place of Funeral
ETA @ Cemetery
Is casket or vault larger than standard, yes
Type option 1
Is casket or vault larger than standard, no
Type option 1
Interment Fee
Funeral Home
Other Charges
Funeral Home address line 1
Funeral Home address line 2
Total cemetery charges
Signature of Funeral Director
Clear
Cemetery lot owner
Contact person
Contact person address line 1
Contact person address line 2
Contact person phone number
Contact person signature line 1
Clear
Contact person signature line 2
Clear
I believe the decedent had the following items pre-paid with the cemetery
Vault
Opening & Closing
Death date on marker
Marker
Mausoleum
Crypt
Other
Other prepaid cemetery items line 1
Other prepaid cemetery items line 2
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