Online Burial Intake Form

    Jersey State Memorial Park

    1. Funeral Home Name:

    2. Director Name:

    3. Director License #:

    4. Director Address:

    5. Director City:

    6. Director State:

    7. Director Phone:

    Deceased Information

    8. Name of Deceased:

    9. Address of Deceased:

    10. Date of Death:

    11. Name of Organization (if any):

    12. Section/Grave Number (if known):

    13. Cemetery Representative:

    Informant/Authorized Person:

    14. Name:

    15. Address:

    16. City:

    17. State:

    18. Phone:

    All rights reserved by Jersey State Memorial Park. All enforced rules and regulations adopted by the Board of Trustees must be adhered to.