INFORMATION ON DECEASED
INFORMATION ON DECEASED Full Name: ________________________________________________ Age: ______ Gender: ______ Date of Birth ________________ Date of Death _________________ Veteran: ☐ Yes ☐ No Requested Funeral Date: _____________ Service Start Time: ______ Cemetery Arrival Time: ______ Funeral Home: _________________________ Cemetery/Location_____________________________ Church/Location: _____________________________________________________________________ ☐ New Site ☐ Existing Site – Name and date of previously interred: _____________________ Type of Burial: ☐ Earth Burial ☐ Vault ☐ Crypt ☐ Cremation INFORMATION ON APPLICANT Full Name: ___________________________________________________________________________ Physical Address: _____________________________________________________________________ Mailing Address: _____________________________________________________________________ Telephone: ______________________ Relation to Deceased:__________________________________ Vault Construction: ___________________________________________________________________ Contractor: ____________ …
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INFORMATION ON DECEASED Full Name: ________________________________________________ Age: ______ Gender: ______ Date of Birth ________________ Date of Death _________________ Veteran: ☐ Yes ☐ No Requested Funeral Date: _____________ Service Start Time: ______ Cemetery Arrival Time: ______ Funeral Home: _________________________ Cemetery/Location_____________________________ Church/Location: _____________________________________________________________________ ☐ New Site ☐ Existing Site – Name and date of previously interred: _____________________ Type of Burial: ☐ Earth Burial ☐ Vault ☐ Crypt ☐ Cremation INFORMATION ON APPLICANT Full Name: ___________________________________________________________________________ Physical Address: _____________________________________________________________________ Mailing Address: _____________________________________________________________________ Telephone: ______________________ Relation to Deceased:__________________________________ Vault Construction: ___________________________________________________________________ Contractor: _____________________________ License #: ____________ Expiration: _____________ Signature __________________________________ Date Submitted ____________________________ SIGN USVI Department of Public Works Burial Plot Permit Application INTERNAL USE ONLY Cemetery Name: ___________________________________________________________________ Location of Burial Site: ______________________________________________________________ Type of Burial: ☐ Earth Burial ☐ Vault ☐ Crypt ☐ Cremation PAYMENT INFORMATION Total Amount Due: $___________ Permit Fees Collected: $___________ Check # if applicable Receipt # Department of Health Burial Permit # ____________________ Date _______________________ The Department of Public Works wishes to extend our deepest condolences on the los of your loved one.