APPLICATION FOR INTERMENT

• 1. Christian and Surname of person to be interred:
• 2. Age of Person to be interred:
• 3. Date of death:
• 4. Address of Deceased:
• 5. Place where death occurred:
• 6. Date and Time when funeral will arrive at Cemetery:
• 7. Number of interments in grave space:
• 8. Name and address of Funeral Director:
• Telephone number/s:
• Signed
  (on behalf of funeral director)
• I request a burial at Pleasley Parish Council’s Cemetery and am aware that NO form of edging kerbs can be erected around the grave.
• Signed
  Date
  (on behalf of family)
• Address:
  
  Post Code:
• Telephone no:

Office use
Date received	Approved	Grave number
Grave number	Cheque received	Registration form received
Registration form sent to Registrar
Entered in burial book	Entered on spreadsheet

Please print, complete and send to :
Ian Weekes, Clerk to the Council,
The Verney Institute, 13 Newboundmill Lane, Pleasley, Mansfield Nottinghamshire NG19 7PL