INTERNMENT FORM
Burial Warrant / Monument Permit
NEZPERCE RUSSELL CEMETERY MAINTENANCE DISTRICT
CEMETERY TO BE BURIED ⎕Nezperce Cemetery ⎕Mt. Calvary Cemetery ⎕Russell Cemetery
Full Name of Deceased __________________________________________________________
Date of Birth ___________________________ Date of Death ____________________________
Funeral Date ___________________________Funeral Time_____________________________
Funeral Home in Charge of Arrangements______________________________________________
Contact Name at Funeral Home and Phone Number_______________________________________
Does the family want to be present for interment? __ Yes __ No
Internment Type:
| ⎕ Open & Closing for a Standard Casket with Vault (3’x9’) $200.00 ⎕ Open & Closing for Cremation without Vault (12’x12’) $50.00 ⎕ Open & Closing for Cremation without Vault (special size) $75.00 ⎕ Open & Closing for Cremation with Vault (special size) $100.00 |
Spot Choices:
| 1 2
3 4 5 6 |
Grave Location: Block ________ Row/Lot ________ Grave ________ Spot _______
⎕Reserved ⎕Re-open ⎕Additional Burial
If Re-opened, Full Name of current occupier________________________________________
If Re-Opened or Additional Burial, Name of Person giving authority_____________________
Reason for Re-Opening________________________________________________________
Monument: Monuments outside the given row will be flush mount with the ground. All other monuments will be within the assigned grave dimensions. Monument placement will be overseen by district and installed professionally. Family is responsible for maintenance of monuments. Cemetery Board has final say on etchings and wording on monuments. All burials will be performed by the NRCMD.
Contact Information
Full Name__________________________________________________________________
Address _________________________ City ________________ State ______ Zip _________
Phone (___)________________________ Cell(___)________________________________
Email ______________________________________
Authorization
I certify to the best of my knowledge that all of the information provided is true and correct. If the cemetery should have any questions or need further information, the first point of contact should be the Contact Information as indicated above.
Signature __________________________ Date _________
Printed Name___________________________
| Office Use Only
______Invoiced ______Obituary ______Transmittal ______Listed ______City Dug ______Cemetery Dug |