Marker Deposit Refund Request

Town of Burgaw

Marker Deposit Refund Request
About this form: To be completed by the funeral home or family of the deceased following the placement of a monument or application of appropriate lettering to an existing monument.
Applicant Details
Name

First NameLast Name
Mailing Address
Phone Number
Email
example@example.com
Marker Deposit Details
Payable to (if different than above)
Mailing Address
Phone Number
Email
example@example.com
Details of the Deceased
Full Name
Date of Death

MonthDayYear
Date
Name of Lot Owner (if known)
Block
Lot
Date Monument was set

MonthDayYear
Date
Acknowledgement
Signature

Clear
Date

MonthDayYear
Date
Town of Burgaw

109 N Walker St, Burgaw, NC 28425

Phone (910) 259-2151

Fax (910) 259-6644

Email cabbood@burgawnc.gov
Should be Empty:

Town of Burgaw