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