Hickerson Memorial Cemetery
Interment/Reservation
Permit Application
Cemetery Plot…………….. 100.0035.4613
491 East Pioneer Avenue
Homer, Alaska 99603
Phone: (907) 235-3130
Fax: (907) 235-3143
clerk@cityofhomer-ak.gov
This permit is for the disposition of human remains or cremains in the Hickerson Memorial Cemetery. No interment is allowed
in the Cemetery unless all fees have been paid and this permit has been signed by the City Clerk or Clerk’s Designee and
the Public Works Department. All interments must be performed at the direction of the City of Homer. This application is a
revocable use permit to reserve up to ten burial plots or cremains plots. This permit does not create an ownership interest
in the real estate which belongs to the City of Homer.
Full Name: ______________________________________________________________________________________
Date: ________________ Date of Interment: __________________
Full Name: ______________________________________________________________________________________
Mailing Address: __________________________ City: ________________ State: __________ Zip: ____________
Phone: _________________________ Email: _________________________________________________________
Relationship to Decedent: __________________________________________________________________________
CKNOWLEDGEMENT OF
PPLICANT
I hereby acknowledge as applicant that I have the legal right to control disposition of the deceased and authorize the
opening of the grave for interment or disinterment of the deceased. I further acknowledge that Hickerson Memorial
Cemetery has specific rules related to who may perform interments or place interment markers within the Hickerson
Memorial Cemetery, and it is my responsibility to consult the Policy and Procedure guide to review these regulations.
I have received a copy of the Hickerson Memorial Cemetery Policy and Procedures
Note:
One casket and up to two cremains may be interred in a standard plot. Up to three cremains may be interred in a
standard plot when there has been no casket interment on the site. Two caskets may be interred in a standard plot, the
second casket being placed on top of the first casket but this must be made known BEFORE the first casket has been
interred.
Applicants Signature: __________________________________________________________________ Date: _______________________
Standard Plot……………………………… $1000 x _______ = ___________
Cremains Plot………………………………$400 x _______ = ___________
Urn Burial…………………………………..$1000 x _______ = ___________
Adult Opening and Closing of Plot....................$500 x _______ = ___________
Infant Opening and Closing of Plot…………$375 x _______ = ___________
Total Fees: = ___________
____________________
Expiration Date (30 years):
____________________
Renewal Date:
____________________
Expiration Date:
____________________
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