INFORMATION ON DECEASED 
Full Name: ________________________________________________ Age: ______  Gender: ______   
Date of Birth ________________ Date of Death _________________  Veteran:  ☐ Yes        ☐ No 
Requested Funeral Date: _____________ Service Start Time: ______ Cemetery Arrival Time: ______ 
Funeral Home:   _________________________ Cemetery/Location_____________________________  
Church/Location:  _____________________________________________________________________ 
☐ New Site       ☐ Existing Site – Name and date of previously interred: _____________________ 
Type of Burial:    ☐ Earth Burial 
 ☐ Vault   
 
 ☐ Crypt  
           ☐ Cremation 
 
INFORMATION ON APPLICANT  
Full Name: ___________________________________________________________________________ 
Physical  Address: _____________________________________________________________________ 
Mailing Address:  _____________________________________________________________________ 
Telephone: ______________________ Relation to Deceased:__________________________________  
Vault Construction:   ___________________________________________________________________  
Contractor: _____________________________ License #: ____________ Expiration: _____________ 
Signature __________________________________ Date Submitted ____________________________ 
 
SIGN
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USVI Department of Public Works 
Burial Plot Permit Application  
 
INTERNAL USE ONLY  
Cemetery Name: ___________________________________________________________________ 
Location of Burial Site:  ______________________________________________________________ 
Type of Burial:    ☐ Earth Burial            ☐ Vault           
☐ Crypt                ☐ Cremation 
PAYMENT INFORMATION 
Total Amount Due: $___________ 
Permit Fees Collected: $___________ 
Check # if applicable  
Receipt # 
 
Department of Health Burial Permit # ____________________    Date _______________________ 
The Department of Public Works wishes to extend our 
deepest condolences on the los of your loved one.