Interment Authorization Form

Information for Deceased Person

Name of Deceased

Veteran?

Yes No

Date of Birth

Date of Death

Location of Death (City, State)

Casket or Cremation?

Casket Cremation

Funeral Home

Responsible for Arrangements

Name

Relationship

Street Address

City

State

ZIP Code

Phone Number

Email Address

Burial Location

Name of Property Owner

Previous Burials in the space to be used

Property Location Number

INTERMENT ORDER: SUBJECT TO OUR RULES, CONDITIONS AND REGULATIONS, YOU ARE AUTHORIZED TO MAKE THE FOLLOWING DISPOSITION OF THE REMAINS OF THE ABOVE NAMED DECEDENT. I HEREBY CERTIFY THAT I AM THE NEXT OF KIN OR AM ACTING ON BEHALF OF THE NEXT OF KIN AND HAVE THE RIGHT TO CONTROL THE DISPOSITION OF THE REMAINS OF SAID DECEDENT. THIS IS YOUR AUTHORITY TO INTER THE REMAINS AS INDICATED ABOVE AND I ASSUME FULL RESPONSIBILITY FOR THEIR IDENTITY WHETHER OR NOT I VIEWED THE REMAINS. I HEREBY AGREE TO PROTECT AND INDEMNIFY THE SAN GABRIEL CEMETERY ASSOCIATION AND ITS ASSIGNS AGAINST ANY AND ALL CLAIMS OR DAMAGES WHICH MAY RESULT ON ACCOUNT OF THIS AUTHORIZATION OR MY FAILURE TO PROPERLY IDENTIFY REMAINS.

I hereby authorize the above interment:

Signature

FOR OFFICE USE ONLY

Block

Lot #

Grave #

Depth

Vault

Valid Permit?

Yes No

Out-of-State/USA Transfer?

Yes No