Name (first individual) *

First Name

Last Name

Name (second individual, if applicable)

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date

MM

DD

YYYY

Having read the “GENERAL POLICIES, REGULATIONS, AND RULES FOR THE USE OF THE COLUMBARIUM,” (“Rules”) of The Bertha E.R. Strosacker Memorial Presbyterian Church Midland, Michigan 48640 (“MPC”) I/we do hereby apply to be granted the use of a niche, the Memorial Garden, and/or the Memorial Wall, in said Columbarium and submit with this Application Form:

Niche

Memorial Garden

Memorial Wall

The Grantee(s) or other Designee(s) whose cremains are to be inurned in the niche, interned in the Memorial Garden and/or whose names are to be honored and remembered on the Memorial Wall is/are:

First Individual: Given Name (Former Name Optional) Family Name

First Name

Last Name

Birth Date

MM

DD

YYYY

Death Date

MM

DD

YYYY

Second Individual

Given Name (Former Name Optional) Family Name

First Name

Last Name

Birth Date

MM

DD

YYYY

Death Date

MM

DD

YYYY

Inscription

Now

Later

Now and later

Clergy, U.S. Military

Yes

No

Relationship to MPC

Member of MPC

Related to a member of MPC

Non-Member

Approvers By

First Name

Last Name

Date

MM

DD

YYYY