Healthcare Headstone Application

Healthcare Headstone Application

Use this application to request a headstone, marker, or plaque to memorialize a patient associated with this healthcare facility. Complete all applicable sections; incomplete applications may be delayed. The applicant certifies that the information provided is true and that the applicant is authorized to request the memorial described herein.

Patient Information

Patient Name:

Date of Birth: Gender: Male Female Other

Emergency & Responsible Contact

Insurance Information

Medical History (for records)

Death & Interment Details

Date of Death: Place of Death:

Headstone / Marker Specifications

Type: Upright Flat (bevel) Bronze Plaque

Material: Granite Marble Bronze Other

Emblems, Symbols, Veteran Information

Religious symbol: Yes Specify:

Military / Veteran emblem: Yes

Installation, Maintenance & Costs

Foundation required: Yes

Applicant is responsible for all costs associated with fabrication, shipping, installation, and any required foundation or cemetery fees. The facility may remove or modify memorials that become hazardous or do not comply with cemetery rules; costs for such action are the responsibility of the applicant or estate.

Authorization & Privacy Acknowledgment

By checking the box below and signing, the applicant certifies under penalty of perjury that the applicant is the next of kin, authorized representative, or legal guardian with authority to request the headstone for the named patient. Applicant authorizes the release of decedent medical and demographic information necessary to confirm identity and eligibility for requested memorial services. Applicant understands that false statements may subject the applicant to civil or criminal penalties.

I certify that I am authorized to apply for this headstone and that the information provided is true and accurate.

HIPAA / Privacy Acknowledgment: I acknowledge receipt of the facility privacy practices and authorize disclosure of protected health information necessary to process this application.

Proof Approval & Processing

The applicant will be provided a final proof of inscription and layout prior to fabrication. Applicant must indicate approval in writing. The facility is not liable for errors in inscription after applicant approval. Rush requests may incur additional fees.

Applicant Certification

I certify under penalty of perjury that I am the person authorized to make this application and that the information contained in this application is true and correct to the best of my knowledge. I accept responsibility for fees associated with manufacture, delivery, installation, and any required foundation work. I release the healthcare facility from liability for any damages resulting from installation in accordance with cemetery or municipal rules, except for damages caused by the facility's gross negligence.

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