No Title

Name

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Lease of

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Ashes lease location of

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Date of Birth of Deceased

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Date of Death of Deceased

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Located in Ashes Bed:

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Located in Row:

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Plot:

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Row:

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Plot:

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I confirm I have received the full and final refund of all monies owing being:

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I confirm I have received the return of the Ashes and Plaque of:

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Lease Holder/Authorised Person to Act:

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Signature (Please sign here):

Date

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