Form Dos-1585 Application For Repair Or Removal Of Dilapidated Or Disrepaired Monuments That Create A Dangerous Condition

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NYS Department of State
Application for Repair or Removal of
DIVISION OF CEMETERIES
One Commerce Plaza
Dilapidated or Disrepaired Monuments
99 Washington Avenue
Albany, NY 12231
That Create a Dangerous Condition
(518) 474-6226
This application applies only to Not-for-Profit Cemetery Corporations and must be completed in full and signed before a notary
public. Funds may be allocated for the above-captioned purposes in accordance with 19 NYCRR §200.11(statutory authority:
Not-for-Profit Corporation Law, §1510-a). The full text of this Cemetery Board Directive appears on the reverse.
AMOUNT REQUESTED
COUNTY IN WHICH
CEMETERY IS LOCATED
CEMETERY NAME
CEMETERY ID NUMBER
NAME OF CEMETERY OFFICIAL
TITLE
STREET ADDRESS
CITY/TOWN/VILLAGE
ZIP CODE
TELEPHONE NUMBERS:
Home (
)
Work (
)
E-MAIL ADDRESS
FAX
Has this cemetery previously applied for and received a grant from the Vandalism,
Abandonment & Monument Repair Fund? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
___ YES* ___ NO
*If YES, when? ____________________ Amount Received: $________________
Was proof of completed work forwarded to the Division of Cemeteries? . . . . . . . . . . . . .
___ YES ___ NO
* * *
1. Provide a description of each damaged monument and/or marker and enclose referenced photos:
2. Attach copies of bids submitted by at least two contractors for the cost of repairs or removal and replacement.
3. Attach proof that the cemetery corporation has given not less than 60-days notice to the last known owner to
repair or remove the monument or marker and that said owner has failed to do so within the time prescribed in
that notice.
* * *
I, the undersigned, duly authorized, swear or affirm under the penalties of perjury that the above-named cemetery has not been able to
obtain sufficient funds from the family of the deceased, that the proposed costs of the repairs or removals and replacements are fair and
reasonable and that the above-described monuments and/or markers are so badly out of repair or dilapidated as to create a dangerous
condition. I further swear or affirm that the information contained in this application is true and correct. I agree that, upon receipt of
monies for the repair or removal of dilapidated or disrepaired monuments that create a dangerous condition, such repairs will be made as
quickly as possible and documentation (receipts and statements) of the repairs and removals will be submitted to the Division of Cemeteries
within 90 days following completion of work.
Signature of
Cemetery Official: _______________________________________________________ Date: ______________________________
On this __________ day of ____________ 20 _____
appeared ___________________________________
known to me to be said person.
___________________________________________
Notary Public
DOS-1585 (08/08)

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