I, Name* , being the owner, heir, or assignee of the owner , of Lot Lot #* , Block   Block #*   , Space Space #*   in the Ishpeming Cemetery, Ishpeming, Michigan, do hereby authorize the interment of:
Name of Deceased*   of Place of Death* on said lot.

First Name*   Last Name*   Date*   

AgeAge* Date of BirthDate of Birth* Date of Death Date of Death*      
Date of Delivery   Date of Deliv.*   Time of Delivery      Time of Deliv. AM PM *      
Clergy   Name of Clergy*   Perpetual Care   Yes   No*       
Resident or Non-Resident    ResidentNon-Resident*              
Married, Single, or Widowed   Married   Single   Widowed* 
Veteran    Yes   No*     Branch*   Funeral Director   blank*