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                 Christ Episcopal Church Memorial Garden

                                  Sparta, North Carolina

                              Application for Burial Space

Date:______________________________

Name of Purchaser:_______________________________________________________

Address:   Street: ________________________________________________________  

                 City:   ___________________________State: ____________ Zip:_________

Telephone:  Home______________________ Office:____________________________

Burial Space Request:

_____________ 1.  In-ground interment of ashes                              Lot #  __________

                                 (specify single or double)

_____________  2. Inurnment of cremains in Columbarium             Niche No. _______    

                                 (specify single or double)

_____________  3. Scattering of ashes in Memorial Garden

Burial Space For:

1.Name:_________________________________________________

Birthdate:___________________ Date of Death:________________

(If this is a double interment or inurnment)

2.Name:_________________________________________________

Birthdate:___________________ Date of Death:________________

The undersigned applicant acknowledges receipt of a copy of the Policies and Regulations established by the Vestry of Christ Episcopal Church and agrees that acceptance of this application and issuance of a certificate of purchase shall be subject to those Policies and Regulations and any subsequent amendments thereto.

_________________________________

Signature of Applicant

Payment Received: $________  by Check No.___________ on ____/____/____. 

Certificate of Purchase Issued:   _____/_____/______