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[Schedule A.]
Church of England Cemetery, [unclear: Purewa], Orakei.

Date.No.

Form to be Filled up Before Issue of Warrant to Inter.

1.	Name of Deceased—
2.	Age—
3.	Late Residence—
4.	Late Rank or Occupation—
5.	Date of Death—
6.	Probable Cause of Death—
7.	Birthplace of Deceased—
8.	Number of Grave on plan—section block lot
9.	Day of Burial—
10.	Hour of Burial—
11.	Name of Minister to Officiate—

Fees paid under this application:—

• For license to enclose land feet by feet
• For breaking ground
• For sinking grave

Signature of applicant—

• Occupation—
• Address—