I/We understand that use of the interment rights to space within the Columbarium shall at all time be subject to all of the provisions of the Rules and Regulations for the operation of The Church of the Epiphany.

Signature of applicant________________________ Printed name of applicant________________________

 Address: ______________________________ City:_________________________ Zip:_________

Telephone Number: (___) ______________ Home (___) ______________ Business

Are you a member of The Church of the Epiphany?_________________ If not, what is your relationship?

Date and Place of Birth:

Name, address and relationship of next of kin or legal representative.

Space Requested: 1 urn ____ 2 urns ____

Desired Niche Number: __________

The Niche (s) in the Columbarium that, in the event of the approval of this application I will be entitled to use is or are designated for the cremated remains of the following:  

 

____________________________________________________________________________________

Full name of applicant - without initials  

Date of birth________________________ Date of death, if applicable________________________

 

Fee Paid: $__________

Witness:

Name________________________________________  

Date ________________________________________