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