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City of Orem

56 N. State St., Orem, UT, 84057, US

Agreement Relinquishing Burial Rights

Pursuant to the Certificate of Burial Right which Grantee rightfully holds, the Grantee hereby relinquishes the certificate of burial back to the City of Orem for

The City shall pay the original value for which the burial right was purchased. The person signing this agreement represents and warrants to the City of Orem that he/she has the authority to grant this action and acknowledges that the City, its employees, agents, or representatives will not be held liable or responsible for any and all claims arising from this grant.

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Remitting address of Grantee:

Cerfiticates Included:

Checking “No” indicates that the original certificates cannot be located. Grantee represents that by signing this agreement that any certificates resurfacing in the future are void and will have no force or effect.

Checking ”Yes” requires that all original or copied certificates are included and attached to this form.

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