Required fields are marked with asterisks (*)

Order for Internment

Before proceeding with an interment the following must be provided to Cemetery Staff:

Order for Interment, signed by Interment Rights Holder;
Burial Permit OR Cremation Certificate (as applicable);
Cheque payable to Loyalist Township for the applicable interment fee.
Funeral Home Cemetery Record/Proof of Death/Cemetery Order/Interment Order

Full Name of Deceased:

Maiden Name (if applicable):

Late Residence:

Father's Name:

Mother's Maiden Name:

Name of Spouse/Next-of-Kin:

Date of Birth:

Place of Birth:

Date of Death:

Date of Internment:

Funeral Director:

Contact:

Phone:

Cemetery & Location:

Section/Row:

Plot(s):

Grave(s):

Casket or Cremation:

Internment Rights Holder(s):

Internment Ordered By:

Relationship to Deceased:

Address:

Phone:

Email:

Consent

Authorization from Township Cemeteries Staff will be completed upon review of the form.

Signature of Interment Rights Holder, the Executor of the Deceased or Legal Representative

Clear

Date:

Signature of the Loyalist Township Cemeteries Staff:

Clear

Date:

When interment is for someone other than the Interment Rights Holder(s) and is being authorized by someone other than the Executor or Legal Representative of the Interment Rights Holder(s) an Interment Authorization Form or Statutory Declaration as supplied by the Operator must be completed. Loyalist Township reserves the right to request further documentation to establish interment rights if required.