Free 52492.xls - Indiana

APPLICATION FOR GRAVE MEMORIAL REMOVAL (IC 14-21-2)
State Form 52492 (1-06)

Division of Historic Preservation and Archaeology 402 W. Washington St., W274, Indianapolis, IN 46204-2739 317-232-1646; FAX 317-232-0693; [email protected]

Instructions: 1. Read all instructions before completing the application. 2. Please type or print clearly in black ink. 3. If additional space is required, please attach additional sheets. 4. A copy of this form shall be placed with the County Recorder's Office in which the stone was found. 5. A copy of this form shall be placed with the County Recorder's Office of the new location, if it is in a different county from where the stone was found. 6. A copy of this form shall be sent to the Department of Natural Resources' Division of Historic Preservation and Archaeology. (see address above)

Filing Date

GRAVESTONE REMOVAL REQUEST Please fill out one form per tombstone BOX #1
Name on Tombstone

GRAVE MEMORIAL INFORMATION

Date of Birth

Date of Death

References to other individuals

Mementos/epitaphs/poems on the tombstone

BOX #2
Location where stone was found Address (number and street) City ZIP Code

ORIGINAL LOCATION OF GRAVE MEMORIAL

County

BOX #3 Image 1: Original placement of grave memorial Image 2: Close-up of grave memorial

GRAVE MEMORIAL IMAGE

BOX #4 Description of relocation area

DESCRIPTION AND IMAGE OF REMOVAL LOCATION Image of grave memorial at new location

BOX #5
Name

GRAVE MEMORIAL REMOVAL CONTACT

Address (number and street)

City

County

ZIP Code

E-mail Address (optional) Signature

REMOVAL OF GRAVE MEMORIAL APPLICATION INSTRUCTIONS
The Grave Memorial Removal Application is completed when an individual lawfully removes a grave memorial. The term "grave memorial" refers to a gravestone, monument, grave marker, or any other type of similar item. A copy of the application is filed with the county recorder of the county where the grave memorial was located before removal, in the office of the County Recorder if it is in a different county from where the stone was found, and to the DNR-Division of Historic Preservation and Archaeology. Please file one form for each grave memorial being removed.

BOX #1 - Grave Memorial Information: The applicant must provide a precise description of all text appearing on the grave memorial as categorized by name, dates of birth and death, references to other individuals, and mementos, epitaphs, poems, and any other additional inscriptions. BOX #2 - Original Location of Grave Memorial Image: Provides the location name, telephone number (if applicable), and address of the where the grave memorial was found. BOX #3 - Grave Memorial Images: Applicants must provide a photograph or printed digital image of the grave memorial in its original location and a close-up photograph or printed digital image of the grave memorial. The photograph may be in color or black and white. BOX #4 - Description and Image of Removal Location: The applicant should provide a written description of the new location of the grave memorial and a photograph or printed digital image of the stone at its new location. BOX #5 - Grave Memorial Removal Contact: Provide the name, mailing address, telephone number, and e-mail address (optional) for the principal individual responsible for filing the application. THE APPLICANT MUST SIGN THIS SECTION OF THE APPLICATION SIGNIFYING THAT THE INFORMATION PROVIDED IS COMPLETE AND CORRECT.