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F O R O F F I C E U S E O N L Y

NYS Department of State

DIVISION OF CEMETERIES

FILE NO ______________________________

One Commerce Plaza

DATE APPROVED ______________________

99 Washington Avenue

Albany, NY 12231-0001

Application for Approval to Transfer Cemetery Property

PLEASE PRINT

1. CURRENT OWNER NAME

2. CEMETERY NAME

STREET ADDRESS

CITY, STATE ZIP+4

3. NUMBER AND LOCATION OF GRAVES TO BE TRANSFERRED, AND HOW ACQUIRED

Number (Quantity)

Location (block, section, plot, etc.)

How and Date Acquired

Yes

4. Are there now any burials in the plot? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

____

5. Were the graves originally acquired for resale? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

____

6. Do you own any unoccupied graves in addition to those listed in Item 3, above? . . . . . . . . . . . . . . .

____*

____

*If Yes, specify number, cemetery, where located and how acquired:

Number (Quantity)

Cemetery

Location (block, section, plot, etc.)

How and Date Acquired

7. Have you made any previous applications to this office for approval of transfer of cemetery property?

____

8. Name and address of proposed purchaser or donee:

9. Is the proposed purchaser or donee related to you? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

____*

____

*If Yes, specify relationship:

10. Is the proposed purchaser in, or affiliated with, the funeral directing business? . . . . . . . . . . . . . . . . .

____

*If Yes, attach notarized statement from purchaser indicating that the plot will be used ONLY for personal use and not for resale:

Applicant Affirmation — I, the undersigned, duly authorized, subscribe and affirm under the penalties of perjury that I

am the owner of the property herein described and that the information provided is true and correct.

Signature of Current Owner(s)

or Authorized Agent(s) ______________________________________________________________

Date ______________________________

(If not owner, attach a written power(s) of attorney.)

On this __________ day of _________________20____

appeared ______________________________________

known to me to be said person.

______________________________________________

Notary Public

Not-for-Profit Corporation Law, §1513(d)(2): Any person who is the sole owner of the burial rights in a cemetery lot, plot or any part thereof, in which

a burial has been made, may give his entire interest, or, if not prohibited by the rules and regulations of the cemetery corporation, any portion thereof

to any person within the third degree of consanguinity to the owner, or, in the event that no such person exists, within the fourth degree of consanguinity

to such owner. Such conveyance shall be made subject to the right of interment of the spouse of any deceased owner, which right said spouse may release

at any time, but no conveyance or devise by any other person shall deprive the surviving spouse of such right. Burial rights shall not be conveyed pursuant

to the provisions of this subparagraph more frequently than once in any ten-year period.

DOS-204 (Rev. 8/08)