Disinterment Authorization - West Jordan City

Decedent Information Name of Decedent Relationship to Decedent

Current Interment Information Cemetery Name Cemetery Address Date of Death/Interment Lot # Site # Section # Other Lot Owner’s Name Lot Owner’s Relationship to Decedent If Lot Owner is NOT the Next-of-Kin signing this form, does Lot Owner concur in request?

Yes No

Re-Interment Information Cemetery Name Cemetery Address Lot # Site # Section #

Reason for Disinterment Please describe

I affirm that the information provided above is true to the best of my knowledge and that the remains of the above-named decedent will be re-interred at the location listed above. I understand that the Funeral Director and/or Sexton will rely on this information to perform the disinterment and re-interment.

Next-of-Kin Authorization Signature Printed Name Address Telephone Number

Notary Acknowledgment County Day Month Year Name (Subscribed and sworn by) Notary Public Signature Printed Name My Commission Expires

The personal data being collected is included in a public record as defined under Utah Code 63G-2- 301 and may be available to the public as provided in Utah Code 63G-2-201. Prior to making a record available to the public, the City of West Jordan redacts private, protected, or controlled information as defined in Utah Code 63G-2-302, 304, and 305. For more information, please contact the city’s Data Privacy Officer: tangee.sloan@westjordan.utah.gov