council supplied memorial plaques - midcoast council · council supplied memorial plaques - v1 ......
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Page 1 of 2Council Supplied Memorial Plaques - V2 - June 2018
About this form Complete this form to provide Council with information in relation to the placement of a memorial plaque at one of Council's Cemetery sites. On receipt of the form, a Council officer will contact the applicant to discuss further. Please note that this form does not order a plaque.
Applicant details
Location of ashesName of the undertaker
Date of burial/cremationDate of deathDate of birth
Last Address of the deceased
Male Female2. Name of the deceased
Name of the undertaker Location of ashes
Date of birth Date of death Date of burial/cremation
Council supplied memorial plaques
Male Female
Last Address of the deceased
1. Name of the deceased
Details of the deceased
Row Allotment No. Garden/Wall No. Lot/Niche No.
General Lawn Gardens Columbarium Walls
Cemetery
Burial Ashes/Wall Ashes/Burial/Garden
No
Single Double
Single Depth Double Depth
YesRemove and replace existing plaque
Plaque details
Type of placementBurial/Placement details
Given namesApplicant surname
EmailMobilePhone
Postal address
Relationship to the deceased
DateSignature (if submitting electronically, print name)
NoYesIs this for memorial purposes only
NoYesAshes to be placed
Page 2 of 2Council Supplied Memorial Plaques - V2 - June 2018
For double placement at the same time, leave a line between inscriptions.
Double DepthSingle Wording on memorial plaque
Additional Comments
Privacy: This information is required to process your request and will not be used for any other purpose without seeking your consent, or as required by law. Your application will be retained in Council's Records Management System and disposed of in accordance with current legislation. Your personal information can be accessed and corrected at any time by contacting Council.
Forster | 4 Breese Parade | PO Box 450 Forster 2428 | 6591 7222
Gloucester | 89 King Street | PO Box 11 Gloucester 2422 | 6538 5250 Taree | 2 Pulteney Street | PO Box 482 Taree 2430 | 6592 5399
www.midcoast.nsw.gov.au
Completed form can be: • Emailed (select the submit buttom below); or • Forwarded by post; or • Lodged at our Customer Service Counter - Monday to Friday (excluding Public Holidays).
How to lodge this form