Form Mo 780-2586 - Cemetery Survey Form printable pdf download

FOR SHPO STAFF USE ONLY

STAFF REVIEWER

DATE ENTERED IN INVENTORY

MISSOURI DEPARTMENT OF NATURAL RESOURCES

ADDITIONAL RESEARCH

❏ YES ❏ NO

NEEDED?

DIVISION OF STATE PARKS

❏ ELIGIBLE (INDIVIDUALLY)

❏ ELIGIBLE (DISTRICT)

CEMETERY SURVEY FORM (PAGE 1 OF 3)

ELIGIBILITY STATUS

❏ NOT ELIGIBLE

❏ NOT DETERMINED

CEMETERY INFORMATION

1. SURVEY NUMBER

2. SURVEY NAME

-CS-

000

0000

3. COUNTY

4. ADDRESS OR DIRECTIONS FROM NEAREST COMMUNITY OR INTERSECTION

5. CITY & ZIP CODE

6. GPS COORDINATES

7. TOWNSHIP/RANGE/SECTION

LATITUDE

❏

VICINITY

LONGITUDE

UTM:

8. HISTORIC NAME (IF KNOWN)

9. CURRENT/OTHER NAME (IF KNOWN)

10. OWNERSHIP

11. PUBLIC ACCESSIBILITY

12. ACCESSIBLE BY

❏ PRIVATE

❏ PUBLIC

❏ UNRESTRICTED

❏ LIMITED HOURS

❏ FOOT

❏ AUTO

❏ BY PERMISSION

❏ INACCESSIBLE

❏ OTHER___________________________

PHYSICAL FEATURES AND SETTING

13. ACREAGE

14. TERRAIN: DESCRIBE IN BOX 46 ON BACK

15. APPROXIMATE NUMBER OF HEADSTONES

16. APPROXIMATE NUMBER

❏ Level

❏ Sloping

❏ None

❏ 100-300

❏ 1000-2000

❏ Over 5000

OF BURIALS (IF KNOWN)

❏ Fairly Level

❏ Steep

❏ 1-50

❏ 300-500

❏ 2000-3000

❏ Other:_____________

❏ Hilly-Moderate

❏ Other:_________________

❏ 50-100

❏ 500-1000

❏ 3000-5000

17. DATE OF EARIEST

18. DATE OF MOST

19. CEMETERY TYPE

20. GENERAL CONDITION OF CEMETERY

KNOWN BURIAL

RECENT BURIAL

❏ Family

❏ Segregated

❏ Well maintained

❏ Overgrown, not identifiable

❏ Municipal/public

❏ Ethnic: _____________________________

❏ Marginally maintained

❏ Not identifiable, but known

❏ Federal/military

❏ Fraternal: (Org.) ______________________

❏ Not maintained

to exist through other

❏ Private/commercial

❏ Religious: (Denom.) ___________________

❏ Overgrown, identifiable

means. Explain in box 43.

❏ Garden

❏ Other:______________________________

21. VISIBLE FROM ROAD?

22. HAVE MARKERS BEEN DAMAGED OR

23. DAMAGED/ENDANGERED BY

24. ESTIMATE OF PERCENT

❏ YES

❏ NO

ARE THEY THREATENED/ENDANGERED?

❏ Animals

❏ Farming operations

OF MARKERS DAMAGED:

❏ Threatened/Endangered

❏ Vandalism

❏ Industrial operations

❏ 10%

❏ 75%

❏ Damaged

❏ Construction

❏ Mowing/Maintenance

❏ 25%

❏ 100%

❏ Neither

❏ 50%

❏ Neglect/Deterioration

❏ Other: ______________________

❏ Vegetation

25. APPROXIMATE AMOUNT OF MARKERS IN EACH CATEGORY

26A. HAVE REPAIRS BEEN ATTEMPTED?

27. ARE MARKERS OR STONES

IN THEIR ORIGINAL LOCATION?

❏ Few

❏ 50%

❏ Most

❏ YES

❏ NO

❏ UNKNOWN

Inscriptions readable:

Inscriptions unreadable: ❏ Few

❏ 50%

❏ Most

❏ YES

❏ NO

❏ UNKNOWN

❏ Few

❏ 50%

❏ Most

26B. REPAIR METHODS USED

Intact and standing:

❏ None

❏ Iron Pins/Bolts

❏ Few

❏ 50%

❏ Most

Broken but standing:

❏ Adhesives

❏ Unknown

❏ Few

❏ 50%

❏ Most

Toppled:

❏ Coatings

❏ Replacment

❏ Few

❏ 50%

❏ Most

Fragments on ground:

❏ Reset

❏ Other: _________________________

❏ Few

❏ 50%

❏ Most

Damaged surfaces:

❏ Few

❏ 50%

❏ Most

❏ Metal Supports

Markers missing:

28. TYPES OF STRUCTURES/OBJECTS PRESENT

29. MATERIALS FROM WHICH MARKERS ARE MADE

30. DECORATIVE CARVINGS AND

31. ARE THERE

SCULPTURAL FORMS FOUND ON MARKERS

MASS GRAVES

❏ Headstone

❏ Entrance

❏ Metal

❏ Concrete

❏ Angel

❏ Hands

❏ Bird

OR BURIALS?

❏ Box tomb

❏ Bronze

❏ Wood

ornamentation

❏ YES

❏ Lamb

❏ Book

❏ Eastern Star

❏ Obelisk

❏ Caretaker’s

❏ Iron

❏ Other:_________________

❏ NO

❏ Religious

❏ Military

❏ Oddfellows

❏ Mausoleum

❏ Zinc

residence

❏ Drapery

❏ Plant/flower

❏ Shriners

❏ UNKNOWN

❏ Receiving vault

❏ Maintenance

❏ Stone

❏ Urn

❏ Anchor

❏ Woodsman

❏ Fences

❏ Granite

sheds/buildings

IF YES,

❏ Gates

❏ Crown

❏ Acronym: _________

❏ Curbing

❏ Comfort stations/

❏ Marble

EXPLAIN IN BOX 44.

❏ Architectural

❏ Statuary

❏ Sculpture

❏ Slate

restrooms

❏ Other: ___________

❏ Mason

❏ Office

❏ Other: _________

forms

HISTORICAL DATA

32. DATE OR YEAR ESTABLISHED

33. LANDSCAPE ARCHITECT/DESIGNER

34. PREVIOUSLY SURVEYED?

❏ YES, Survey Name: ___________________

❏ NO

35. NOTEWORTHY DATE/PERIOD: FURTHER DESCRIPTION IN BOX 44 ON BACK.

36. BUILDER

37. ON NATIONAL REGISTER?

❏ YES

❏ NO

❏ INDIVIDUAL

❏ CONTRIBUTES TO A LISTED DISTRICT

Nomination: ______________________________________________________

OTHER

38A. CONTACT FOR CEMETERY (NAME AND CONTACT INFORMATION)

38B. OWNER INFORMATION (NAME AND CONTACT INFORMATION)

39. FORM PREPARED BY (NAME AND ORGANIZATION)

40A. CONTACT IS:

40B.:

41. SURVEY DATE

42. DATE OF REVISIONS

❏ OWNER

❏ MANAGER

❏ CEMETERY BOARD MEMBER

❏ OTHER

❏ CONTACT FOR ACCESS

MO 780-2586 (07/17)

Form Mo 780-2586 - Cemetery Survey Form

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