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Unnamed: 0 | APPLICATION FOR GRAVE MEMORIAL REMOVAL (IC 14-21-2)                                        State Form 52492 (1-06) | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Division of Historic Preservation and Archaeology | Unnamed: 8 | Unnamed: 9 | Unnamed: 10
 |  |  |  |  |  |  | 402 W. Washington St., W274, Indianapolis, IN  46204-2739
 |  |  |  |  |  |  | [PHONE]; FAX [PHONE]; [EMAIL]
Instructions:
1. Read all instructions before completing the application.
2. Please type or print clearly in black ink. |  |  |  |  |  |  |  | Filing Date
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)
GRAVESTONE REMOVAL REQUEST
Please fill out one form per tombstone
BOX #1 |  |  |  |  |  |  |  |  |  | GRAVE MEMORIAL INFORMATION
Name on Tombstone
Date of Birth                                                                                    Date of Death
References to other individuals
Mementos/epitaphs/poems on the tombstone
BOX #2 |  |  |  |  |  |  |  |  |  | ORIGINAL LOCATION OF GRAVE MEMORIAL
Location where stone was found |  |  |  |  |  |  | Telephone Number
Address (number and street)
City |  |  |  | ZIP Code |  |  | State |  | County
BOX #3 |  |  |  |  |  |  |  |  |  | GRAVE MEMORIAL IMAGE
Image 1: Original placement of grave memorial |  |  |  |  | Image 2: Close-up of grave memorial
BOX #4 |  |  |  |  |  |  |  |  |  | [NAME] AND IMAGE OF REMOVAL LOCATION
Description of relocation area |  |  |  |  | Image of grave memorial at new location
BOX #5 |  |  |  |  |  |  |  |  |  | GRAVE MEMORIAL REMOVAL CONTACT
Name |  |  |  |  |  |  | Daytime Telephone Number
Address (number and street)
City |  |  |  | County |  |  | State |  | ZIP Code
E-mail Address (optional)
Signature |  |  |  |  |  |  | Date
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 [NAME] AND CORRECT.