Christ Episcopal Church Memorial Garden

                                                                                              Sparta, North Carolina

                                                                                        Application for Burial Space

Date:______________________________

Name of Purchaser:_______________________________________________________

Address: Street: ________________________________________________________

        City: ___________________________State: ____________ Zip:_________

Telephone: Home______________________ Office:____________________________

Email: ______________________________

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: _____/_____/______