4. ***IMPORTANT*** This is only a request. Burial must be confirmed verbally by cemetery office.

   Please complete the following information and you will be contacted as soon as possible by cemetery office.

6. Funeral Home Information
8. Funeral Home Name:*
10. Contact Name:*
12. Contact Email:*
14. Contact Telephone Number:*
18. Deceased Information
20. Sex:*

    1. M
    2. F
22. First Name:*
23. Middle Name:
24. Last Name:*
25. Maiden Name:
27. Last Residence:
29. Birth Date:
    Birth Date:
30. Place of Birth:
32. Death Date:
    Death Date:
33. Place of Death:
35. Marital Status:
    -- Select One --MarriedSingleDivorcedWidowInfantChildNever Married
37. Spouses Name:
39. Mother's Name (Please include maiden name):
41. Father's Name:
45. Next of Kin:
47. Name:
49. Relationship to Deceased:
51. Street Address:
53. Email:
55. Telephone Number:
57. Veteran?*

    1. Yes

    1. No
59. Conflict:
    -- Select One --American RevolutionIraq WarAfghanistanKosovoBosniaSomaliaGulf WarVietnam WarWorld War IIWorld War ISpanish American WarIndian WarsCivil WarMexican WarWar of 1812War Against the Islamic State (ISIS)
61. Branch:
    -- Select One --Air ForceAir Force ReserveAir National GuardArmyArmy National GuardArmy ReserveCoast GuardCoast Guard ReserveMarine CorpsMarine Corps ReserveNavyNavy ReserveUnknown
63. Military Rank:
    -- Select One --AdmiralStaff SergeantSergeantRecruitPrivateMajorLieutenantFirst LieutenantCorporalColonelCaptainAirmanUnknown
67. Burial Information
69. Burial Location:
    -- Select One --Forest RoseMaple GroveElmwoodUnknown
71. Requested Date/Time Of Burial:
    Requested Date/Time Of Burial:

    Requested Date/Time Of Burial:

    * Burial times are 9:00am-2:30pm

    * Closed all federal holidays

    * Full list of closed dates here

73. Type of Vault:*
77. Service Information
79. Service Location:
    -- Select One --Funeral HomeChurchGraveside
81. Church Name:
85. Already Have Plot(s)?*

    1. Yes

    1. No
87. Cemetery:
89. Section:
91. Lot / Row:
93. Grave:
95. Need to Purchase Plot(s)?*

    1. Yes

    1. No
97. Purchaser's Name:
99. Purchaser's Email:
101. Purchaser's Telephone Number:
103. Relationship to Deceased:
107. Attach Document:
108. Attach another document?

     1. Yes

     1. No
110. Attach Document:
111. Attach another document?

     1. Yes

     1. No
113. Attach Document:
114. Attach another document?

     1. Yes

     1. No
116. Attach Document:
117. Attach another document?

     1. Yes

     1. No
119. Attach Document:
123. I understand that the submittal of this form does not confirm any burial and this is only a request. Burial must be confirmed verbally by the cemetery office.*

     1. I understand.
Leave This Blank:


125. 1. Receive an email copy of this form.
126. Email address

     This field is not part of the form submission.

127. Submit

* indicates a required field