Grave Space Details & Exclusive Right of Burial Deed holder/s information

Location & Grave Space Reference

Exclusive Right of Burial Deed number

Exclusive Right of Burial Deed holder/s 1. 3.

2. 4.

Is the deceased the sole Exclusive Right of Burial holder for this grave? YES If YES, complete SECTION A below

NO If NO, complete SECTION B below

SECTION A: Authorised Representative of the Deceased to complete

As the authorised representative, I declare that I have read, understood and agree to comply with the Cemetery Regulations relating to Herne Road Cemetery.

Relationship to deceased

Forenames & Surname

Address (including postcode)

Telephone/mobile number

Email address

Signature of authorised representative: Date:

SECTION B: Exclusive Right of Burial (EROB) deed holders to complete

As the EROB holder, I consent to this interment. I declare that I have read, understood and agree to comply with the Cemetery Regulations relating to Herne Road Cemetery.

Forenames & Surname

Address (including postcode)

Telephone/mobile number

Email address

Signature of EROB holder: Date:

As the EROB holder, I consent to this interment. I declare that I have read, understood and agree to comply with the Cemetery Regulations relating to Herne Road Cemetery.

Forenames & Surname

Address (including postcode)

Telephone/mobile number

Email address

Signature of EROB holder: Date: