INFORMATION ON DECEASED 
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INFORMATION ON APPLICANT

INTERNAL USE ONLY



Cemetery Name:



Location of Burial Site:



Type of Burial:



OD Earth Burial



OO Vault



C2 Crypt



[] Cremation



ee



Total Amount Due: $



Permit Fees Collected: $



Check # if applicable



Receipt #



Department of Health Burial Permit #



Date



The Lynsbuste ible [nares



DEPARTMENT OF PUBLIC WORKS



UNITED STATES VIRGIN ISLANDS



Page 2



USVI Department of Public Works



Burial Plot Permit Application