......................................................................... CEMETERY
Complete this form in full using BLOCK CAPITALS and tick the appropriate option.
APPLICANT DETAILS
DECEASED’S DETAILS
APPLICATION FOR A BURIAL IN A CREMATED REMAINS
SECTION
Deceased Name In Full ................................................................................................................... Age ........................ Sex ............................
Home Address ......................................................................................................................................................................................................
........................................................................................................................... Postcode ......................... Religion ...........................................
Place of Death .................................................................................................. Date of Death ............................................................................
Day, date and time of interment:.............................................................................................................................................................................
Full Name ................................................................................................................................................................................................................
Address (if different from above) ..........................................................................................................................................................................
............................................................................................................................................................ Postcode ....................................................
Your relationship to the deceased ........................................................................................................................................................................
FUNERAL DIRECTOR DETAILS
Please return this form to: Bereavement Services,
Willenhall Lawn Cemetery, Bentley Lane, Short Heath, Willenhall WV12 4AE. Telephone: 0300 555 2848
Company Name ............................................................................................. Telephone Number ...............................................................
Size of Coffin ........................................................................................... Family Back Fill? Y/N if yes enclose form
Inter. No: .......................................................................
Receipt No: ...................................................................
Fees: .............................................................................
Date letter sent: ...........................................................
Type of grave: ...............................................................
FOR OFFICE USE ONLY
TO PURCHASE THE EXCLUSIVE RIGHT OF BURIAL FOR 100 YEARS AND INTERMENT IN A
CREMATED REMAINS GRAVE IN A LAWN SECTION
APPLICATION FOR EXISTING PURCHASED GRAVE TO BE RE-OPENED
Grave number to be re-opened ......................... In which (full name)..........................................................................................
was interred on (date)......................................... (Please enclose the grant of right to burial if available)
I declare that I am the:
Registered Owner Executive of the Registered Owner Next of Kin of the Registered Owner
and that I idenmnify Walsall Council against all claims which may be suffered in consequence.
If the grave rights owner is deceased a statutory declaration will be required before any memorialisation can take place.
BURIAL OPTIONS
I agree to adhere to the council rules and regulations in relation to cemeteries and crematorium. I understand that a
copy of these can be found on the council website and that I can request a hard copy of these if I wish to.
I understand and accept that the council:
• will take all reasonable care to comply with the instructions given above
• reserves the right to cancel an interment in the event of severe weather or other circumstances outside the council’s
control
• will endeavour to give such notice as circumstances allow when cancelling
• will not accept liability for any additional costs incurred in these circumstances
• will send me information relating to cemetery facilities and memorials
Walsall Council will only ever create, use, store and or share your data in accordance with the data protection
regulations and conditions for processing as set out in our privacy statement(s) which are available online via
http://go.walsall.gov.uk/privacystatement. Should there be a requirement to share your information for any other
purposes outside of our public functions, tasks and statutory requirements, Walsall Council will always ensure
consent is appropriate wherever necessary.
Applicants Signature .......................................................... Date..............................................................................................
.
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