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OFFICE USEVersion: 1.0	EROB Deed	Register of Burials
	Green Form OR Coroner's Form	Location & Grave Space ref
	Coffindimensions	KPS booked
	St Thomas' Chapel required	FD & Invoice Date

## HERNE ROAD CEMETERY, CROWBOROUGH ## APPLICATION FOR INTERMENT ## COFFIN BURIAL This application is made subject to the Herne Road Cemetery Regulations of Crowborough Town Council and must be delivered to Crowborough Town Council, Council Offices, Pine Grove, Crowborough, East Sussex, TN6 1DH at least seven days prior to any interment. This application must be accompanied by either a Notification of Burial or Coroner's Order.

Personal Information of the Deceased
Full name of deceased
Permanent address of deceased at time of death
Was the deceased a parishioner?	YES	NO	(Refer to Parishioner Guidelines at the end of the form)
Age of deceased
Date of Death
Place of Death
Interment Details
Date of Interment
Time of Interment
Hire of St Thomas’ Chapel	YES	NO	If YES, complete St Thomas’ Chapel Hire Form
Depth of burial	SINGLE		DOUBLE		RE-OPEN
Exact Coffin dimensions	LENGTH:		WIDTH:		HEIGHT:
Officiating Minister – if applicable
Funeral Director Details
Contact name Name of Funeral Director Address Telephone number Email Address
Signature of Contact:				Date:

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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:

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SECTION B continued: 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:
Parishioner Guidelines In order to determine which fees to charge, the Council will use the last permanent address of the deceased. In the case of a former resident who has lived in the parish of Crowborough for at least five years immediately before moving to a residential, care or nursing home outside Crowborough, the parishioner rate will apply for their first five years in the home; after this period the non-parishioner rate will apply.
General Data Protection Regulations All data contained and submitted in this form will be processed in line with our Privacy Notice. You can read our Privacy Notice on our website: https://www.crowboroughtowncouncil.gov.uk/privacy-notice/ A paper version is available on request from the Cemeteries Officer.
Crowborough Town Council Contact Details
Cemeteries Officers Crowborough Town Council Council Offices, Pine Grove Crowborough TN6 1DH	Telephone: 01892 652 907 Email: cemeteries@crowboroughtowncouncil.gov.uk Website: www.crowboroughtowncouncil.gov.uk Office hours: Monday to Thursday - 9am to 5pm; Friday - 9am to 4.30pm
Version: 1.0