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POL: APPLICATION FOR COUNTY BURIAL APPLICATION JEFFERSON COUNTY COUNTY BURIAL INSTRUCTIONS TO THE PERSON APPLYING FOR COUNTY BURIAL An individual who knows the financial situation of the deceased should complete the application. All assets and income of the deceased must be included in this application. The application should be submitted to the Jefferson County Commissioner's Office at the Jefferson County Courthouse in Boulder. The application will be reviewed and a determination made for County participation in payment of funeral expenses. Please Complete All Questions NAME OF DECEASED DATE OF DEATH RESIDENCE NEXT OF KIN OR KNOWLEDGEABLE REPRESENT A TIVE ADDRESS TELEPHONE SOURCE OF INCOME OF DECEASED W AS THE DECEASED A VETERAN? YES NO_ DID THE DECEASED OWN ANY PROPERTY? YES - NO - PLEASE SPECIFY DID THE DECEASED HAVE ANY OTHER ASSETS? YES - NO - PLEASE SPECIFY DID THE DECEASED OWN ANY INSURANCE POLICIES? YES NO - - PLEASE SPICIFY I hereby state that the information provided is true to the best of my knowledge and make application for burial on behalf of the deceased individual. Signed Date Approved Date