Name(s) of Applicant As you wish them to be shown on the Certificate of Right of Inurnment Street Address. City, State, Zip

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2 First Presbyterian Church 9 North Sixth Street, Fernandina Beach, Fl APPLICATION TO PURCHASE A RIGHT OF INURNMENT (Please Type or Print Clearly - Separate Application Required for Each Niche) Name(s) of Applicant As you wish them to be shown on the Certificate of Right of Inurnment Street Address City, State, Zip Telephone ( ) Niche Requested (Subject to Approval): Wall (I,II,III) Column (A-F) Row (1-5) Eligibility for Purchase Due To: FPC Member ; OR Former FPC Member in years -- ; OR Relative of FPC Member (name) Relationship Name(s) of Eligible Person(s) expected to be inurned. The second line may include first and middle names, first name and middle initial, or first, middle, maiden names. These are requested for application purposes, however the granite niche cover will be engraved using the names as provided later on an Individual Inscription Order Form. Person 1 Last Name First and Middle Name Date of Birth (Month (Jan) xx, xxxx) Relationship to Applicant Person 2: Last Name First and Middle Name Date of Birth (Month (Jan) xx, xxxx) Relationship to Applicant If the address for either person 1 or 2 is different than above, please furnish the addresses below. Terms of Purchase: 1. Full Payment of $2,000 Submitted with Application by: Check (# ) 2. The Applicant agrees that the Columbarium Rules, Policies and Regulations governing operation of the Columbarium as now existing or which may exist in the future are a part of this application for all purposes, and acknowledges receipt of a copy of the existing Rules, Policies and Regulations. 3. The Applicant understands and acknowledges that First Presbyterian Church of Fernandina Beach and its authorized agents and representatives shall be liable only for acts of gross negligence and intentional wrongdoing, and in no event shall any such party be liable for any monetary awards in excess of the purchase fee paid by the applicant.

3 Applicant s Signature Date Addresses if different than above. Person 1: Name Address City State Zip Person 2: Name Address City State Zip DO NOT WRITE IN THIS BOX Application Received by: Date Application Approved by Columbarium Committee: Date Certificate of Inurnment Executed: Date File Name: FPC Niche Application PROPOSED.doc

4 Certificate of Right of Inurnment Columbarium of First Presbyterian Church Fernandina Beach, Florida Date:, 2017 This certificate acknowledges that the First Presbyterian Church of Fernandina Beach, Florida has conveyed to the following person or persons, (herein called Grantee (s)) Inurnment Rights in a Niche in the Columbarium of the First Presbyterian Church, which Niche is identified as follows: Wall, Column, Row The Niche shall be used for the inurnment of the cremated remains of the Grantee (s) and/ or a member of the Grantee s immediate family, and shall be held and used under the terms of the Rules, Policies and Regulations Related to the Columbarium of First Presbyterian Church of Fernandina Beach, Florida. Grantee (s), or the heirs or next of kin of Grantee (s) if Grantee (s) is (are) deceased, shall have the right at any time to withdraw any urn or urns deposited in the niche described herein, provided that such withdrawal shall terminate any inurnment rights granted by this Agreement and shall return the control of such rights to the Church, which may then resell such rights. There shall be no refund of any portion of the purchase price provided for hereunder. The Inurnment Rights in the Niche are not transferable by the Grantee (s) to another person. However, should the Grantee (s) no longer desires to use the Niche, and the niche has not been used or the niche face inscribed, by giving written notice, First Presbyterian Church will refund to Grantee (s) the amount originally paid. First Presbyterian Church, Fernandina Beach, Florida By: Authorized Representative ATTEST: Acknowledges and Accepts: Grantee (s):

5 The Columbarium of First Presbyterian Church 9 North Sixth Street, Fernandina Beach, Fl INDIVIDUAL NICHE INSCRIPTION ORDER FORM TO THE COLUMBARIUM COMMITTEE OF FIRST PRESBYTERIAN CHURCH OF FERNANDINA BEACH, FLORIDA: Subject to the Rules, Policies and Regulations of the Columbarium Committee, you are hereby requested and authorized to have placed upon the cover of Niche Number: Wall (I,II,III), Column(A-F), Row (1-5), in which the cremains of and have been or are registered to be inurned, the engraved inscriptions as follows: First Inscription (please type or print carefully. If only one name is to be inscribed at this time, complete only the first inscription and complete the instructions below as to which position on the niche cover it should be placed.) The second line may include first and middle names; first name and middle initial; or first, middle, maiden names, limited to 22 characters including spaces. Indicate dates using the format: Jan xx, xxxx. Last Name: First and Middle Name: (Date of Birth) (Date of Death) If deceased, cremains: are available; OR are not available for inurnment. A copy of the obituary is attached? Yes/ No Second Inscription (please type or print carefully): Last Name: First and Middle Name: (Date of Birth) (Date of Death) If deceased, cremains: are available; OR are not available for inurnment. A copy of the obituary is attached? Yes/ No I/We request that the First inscription OR Second inscription OR First to Die be located in the upper position on the niche face. (If only one, the inscription will be centered.) I certify that the above inscription text is correct and any changes shall be made at my expense. Signed Date Authority for request (check one): Owner of Right; Owner s Heir; Executor; OR Administrator. COMPLETE ALL INFORMATION REQUESTED ABOVE - DO NOT WRITE IN THIS BOX Acknowledged for the Columbarium Committee: Signed Date Niche Inscription Ordered : Date - By File name: Niche Inscription Form PROPOSED.doc

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