Interment Request

Casket or Cremains?

Decedent’s Name

Date of Death

Relationship to Lot Owner

Possession of original deed or other documentation may be required as proof of lot ownership.

Lot Owner’s Name

Requestor’s Name

Requestor’s Address

Requestor’s Phone Number

Section

Lot

Grave

Provide details of grave placement

Arrival at the cemetery

If Funeral Home has been engaged to handle arrangements:

Funeral Home Name

Funeral Home Rep. Name

Funeral Home Phone Number

Your Email Address

By checking this box I hereby certify that I am the OWNER or REPRESENTATIVE of the owner of the above cemetery lot and that OWNER has given authority to make disposition of the remains of said decedent as above indicated. I hereby certify and represent that I have the legal right to make this authorization and I agree to hold Village Cemetery harmless from any liability on account of such authorization and interment.