Application details
Application number
I, (full name)
First
Surname
Address
Zip Code
hereby apply to the Utoy Cemetery Assoc., Inc. for a permit to execute work described below at:
Utoy Cemetery
Location of plot
on the grave of the late:
Full name of deceased
Date of death
Funeral director for the deceased
Type of work i.e. headstone, plaque, memorial,
or change/addition to an existing headstone,
plaque or memorial
Monumentalist/supplier responsible for physical
work*
*Persons conducting site works must have undertaken a site and safety induction and all installation work must be in compliance with the Utoy Cemetery
standard for headstones, or its subsequent amendments.
Dimensions of headstone/plaque to be installed
Headstone:
Width
in
Base:
Width
in
Flat/Slant Marker: Width
in
Height
Depth
Depth
in
Thickness
in
in
Thickness
in
in
Thickness
in
Please state headstone/marker
material (Granite or Marble))
Dec
Declaration of applicant
Depth
Thickness
I declare that to the best of my knowledge, that the information provided is true and correct, also the plot
fees and burial and/or cremation charges have been paid in full.
I understand the Utoy Cemetery is NOT a perpetual care and that the Utoy Cemetery Association, Inc. is not
responsible for maintenance of the memorial described herein.
I agree that a photo of the headstone/marker can be published in the cemetery search facility on the Utoy
Cemetery website.
Yes
No
Yes
No
Signature of applicant
State relationship status to the deceased (i.e. spouse, civil union partner, defacto partner of the
deceased, child or parent of the deceased, or other near relative of the deceased, or executor or
solicitor for the deceased).
Date of application
© New Plymouth District Council 2009
APP-098-F,Oct 09,V4,Page 1 of 1