Maple Hill Burial Permit Request

City of Evansville

31 S Madison St | PO BOX 529, Evansville, WI 53536 (608) 882-2266

*=required

Today's Date: *

Deceased's Information

Last Name: *

First Name: *

Middle Name:

Maiden:

Last Known Address: *

City: *

State: *

Zip: *

Date of Birth: *

Date of Death: *

Veteran: * Yes No

Contact Information

(Who should be contacted about this form)

Last Name: *

First Name: *

Address: *

City: *

State/Zip: *

Phone: *

Email: *

Funeral Home Name (or Relationship to Deceased): *

Space Information

Burial Type: * Full Burial Cremation

Location of Burial:

Section: *

Block: *

Lot/Row: *

Space: *

Is the Deceased the Lot Owner?: * Yes No

Date and Time of Funeral: *

Expected Time at Cemetery: *

Vault Company Used: *

Cremains Burial

Do you require a setup with greens for the interment?: * Yes No

Do you require any dirt to be left near the hole?: * Yes No

Do you require the sexton to fill the grave while you observe?: * Yes No

Will a representative from the funeral home be present?: * Yes No

Will a minister be present?: * Yes No

Do you require chairs?: * Yes No

Do you require a tent? (tent rental fee-$100): * Yes No

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City Of Evansville - WI

Maple Hill Burial Permit Request

City of Evansville

31 S Madison St | PO BOX 529, Evansville, WI 53536 (608) 882-2266

Park Improvements