Stokenchurch Parish Council
Cemetery Work Permit Form
Permit forms are to be returned to the Parish Council Office, Longburrow Hall, Park Lane, Stokenchurch, Bucks, HP14 3TQ. Please complete all relevant areas of this application.
Should the application be incomplete, it will be returned unprocessed.
Grave No..………………………. Full name(s) of deceased………………………………………………………………
……………………………………………………………………………………………………………………………………………….
I, the undersigned (Mason), hereby make application for consent to (tick one option from both columns):
□ Erect a new memorial □ Remove memorial to workshop
□ Add an additional inscription to existing memorial □ Work on site
□ Add an owner’s inscription to existing memorial
(current owner of grave is deceased)
□ Renew an existing memorial
□ Renovate existing memorial - specify works:
……………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….
In accordance with the accompanying particulars and sketch, I hereby agree to bear the cost of any damage that may be caused to the Cemetery or to any of the graves, paths, memorials, turf etc consequent upon the execution of the above work. I agree to abide by the Cemetery Regulations and procedures that are in force.
Mason’s Name……………………………………………………………………………………………………………………….
Full Address……………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
Post Code………………………….. Telephone Number…………………………………………………………………..
Mason’s Signature………………………………………………………………….. Date…………………………………….
Print Name………………………………………………………………………………………………………………………………………….
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The following must be authorised by the grave owner. In case of owner’s inscription, this is to be authorised by the person acting on behalf of the deceased owner, next of kin or person who arranged the funeral.
I undertake to keep the memorial in good repair and condition. I, the undersigned (grave owner/person acting on behalf of deceased owner) hereby consent to the execution by
Mason’s Name……………………………………………………………………………………………………………………….
of the work set out in this application on the above grave.
Full Name: Mr/Mrs/Miss/Ms………………………………………………………………………………………………………………
Full Address…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………….
Post Code…………………………………… Telephone Number…………………………………………………………………….
Signature………………………………………………………………………… Date……………………....................................
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To be completed by the Mason for new memorial/renovation applications only:
Drawing of memorial to be erected on Grave No ……………………….
Material………………………………………………………………………………………………………………………………………………………………………………
Dimensions of headstone/tablet:
Height………….………….Depth………………………….Width……………………………..Thickness……………………………
Dimensions of base:
………………………………..Width………………………….Depth…………………………….Thickness………………………………
Overall memorial size including headstone and base from ground level:
Height………………………………………. Width…………………………………
NB The exact dimensions of the proposed memorial must be given in every case. You must specify the dimensions in relation to the drawing of the memorial and include your method of fixing. If necessary you may supply this information on a separate sheet and attach it to this application.
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To be completed by the Mason for new memorial/inscription applications:
Method of lettering e.g. cut/gilded etc……………………………………………………………………………………………………………………………………
Colour of lettering (specify none if cut only)…………………………………………………………………………………………………………………………..
Exact wording of new inscription…………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………………………………….
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FOR OFFICE USE ONLY
Date……………………………………………………………………………………. Appointment date and time……………………………………………………
Memorial passed Yes/No If no, reason for failure……………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………………………………………………….......
……………………………………………………………………………………………………………………………………………………………………………………………….
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