Name ................. Address .....................
City ................. Telephone ...................
Items 2 through 6 must be completed by the executor of the decedent's
estate, a personal representative, owner's surviving spouse, or surviving
heir.
2. The decedent's name is ..............................
3. The date of decedent's death was ....................
4. The decedent's place of residence immediately before
his or her death was ........................................
5. My relationship to the decedent is .................. and I am authorized to sign and file this affidavit.
6. At the time of death, the decedent (had no) (had a) surviving spouse.
The name of the surviving spouse, if any, is ....................., and
he or she (has) (has not) remarried.
7. The following is a list of the cemetery interment rights
that may be used by the heirs if the owner is deceased:
.............................................................
.............................................................
8. The following persons have an ownership interest in and the right to use the cemetery interment rights
in the order of their death:
.......................... Address ..........................
.......................... Address ..........................
.......................... Address ..........................
.......................... Address ..........................
.......................... Address ..........................
.......................... Address ..........................
.......................... Address ..........................
9. This affidavit is made for the purpose of obtaining the consent of the
undersigned to transfer the right of interment at the above mentioned cemetery
property to the listed heirs. Affiants agree that they will save, hold
harmless, and indemnify Cemetery, its heirs, successors, employees, and
assigns, from all claims, loss, or damage whatsoever that may result from
relying on this affidavit to record said transfer in its records and allow
interments on the basis of the information contained in this affidavit.
WHEREFORE affiant requests Cemetery to recognize the above named
heirs-at-law as those rightfully entitled to the ownership of and use of said interment
(spaces) (space).
THE FOREGOING STATEMENT IS MADE UNDER THE PENALTIES OF PERJURY.
(A FRAUDULENT STATEMENT MADE UNDER THE PENALTIES OF PERJURY IS PERJURY AS
DEFINED IN THE CRIMINAL CODE OF 2012.)
Dated this ........ day of .............., .....
................... (Seal) (To be signed by the owner or
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Subscribed and sworn to before me, a Notary Public in and for the County and
State of .............. aforesaid
this ........ day of ..............., .....
............................ Notary Public.
(Source: P.A. 97-1150, eff. 1-25-13.)
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