Burial Site Inventory Form

Burial Site Inventory Form

(10)   CODE NUMBER (30) COUNTY

(15) BURIAL SITE NUMBER

(20) SITE NAME

(40, 45) CIVIL TOWN(S)

(50)   TOWN North RANGE SECTION

(60)   QUARTER-SECTIONS (at least 3 quarter sections)

(70)   QUARTER-SECTION GRID ALIGNMENT (N,S,E, or W edge; or NE,SE,SW,NW corner)

(80)   TOWN North RANGE SECTION

(90) QUARTER-SECTIONS (at least 3 quarter sections)

(100)   QUARTER-SECTION GRID ALIGNMENT (N,S,E, or W edge; or NE,SE,SW,NW corner)

UTM COORDINATES: (110) Zone: (112) Easting (114) Northing

(120)USGS QUADRANGLE MAP (Name: 7.5’):

(130)   RELATION TO LANDSCAPE FEATURES:

(135)   LEGAL DESCRIPTION (metes & bounds) - including sufficient contiguous land necessary to protect burial site from disturbance:

DISTANCE AND DIRECTION FROM NAMED ROADS, STREAMS, LAKES, VILLAGES

(317) RELIGIOUS AFFILIATION OF BURIAL SITE

1. Baptist / 2. Catholic
3. Church of Christian Scientist / 4. Church of Jesus Christ of Latter-Day Saints
5. Congregational / 7. Eastern Orthodox
6. Disciples of Christ / 9. Evangelical
8. Episcopal / 11. Adventist
10. Holiness- Pentecostal / 13. Methodist
12. Lutheran / 15. Presbyterian
14. Moravian / 17. Unitarian- Universalist
16. Reformed Churches / 19. Midewiwin
18. Jewish / 21. Other
20. Unknown

(318)   PREDOMINANT ETHNIC AFFILIATION OF BURIAL SITE (IF ANY)

1. Afro-American / 2. Albanian
3. American Hispanic / 4. Arab
5. Armenian / 6. Asian
7. Austrian / 8. Belgian
9. Bohemian / 10. Bulgarian
11. Canadian / 12. Croatian
13. Danish / 14. Dutch
15. English / 16. Estonian
17. Finnish / 18. French
19. German / 20. Greek
21. Hungarian / 22. Icelandic
23. Irish / 24. Italian
25. Latvian / 26. Lebanese
27. Lithuanian / 28. Luxembourgian
29. Native American / 30. Norwegian
31. Polish / 32. Portuguese
33. Rumanian / 34. Russian
35. Scottish / 36. Serbian
37. Slovakian / 38. Slovenian
39. Spanish / 40. Swedish
41. Swiss / 42. Syrian
43. Turkish / 44. Ukranian
45. Welsh / 46. Other Euro-American
47. Chippewa/Ojibwa / 48. Eastern Dakota
49. Fox / 50. Huron
51. Kickapoo / 52. Mascouten
53. Menominee / 54. Miami
55. Oneida / 56. Ottawa
57. Potawatomi / 58. Sauk
59. Stockbridge/Munsee/Brothertown / 60. Winnebago

(420) DESCRIPTION OF SITE, FEATURES:

(If historic cemetery, be sure to include span of death dates on markers, approximate number of markers, types of markers (stone, wood, metal or other), unusual features, notable individuals (if any), threats to site.)

ATTACH SITE MAP. If historic or modern cemetery, and graves are in regular pattern simply denote limits of land area occupied and describe grave spacing. If there are few graves and they are irregularly spaces, map position of each grave.

SITE REPORTED BY: (500) NAME (510) DATE

(520)   Unverified Field Checked

(535)   FIELD NUMBER(S):

(540)   BIBLIOGRAPHIC REFERENCES:

FOR SHWS USE ONLY

(545)   CATALOGUED Yes No (546) DATE CATALOGUED

(550)   SHPO COMPLIANCE CASE (S): (560) SHPO S&P GRANT(S):

(570)   NRHP CERTIFICATION: (572) DATE(S) OF NRHP CERTIFICATION:

(571)   REVIEW BOARD DATE: (580) LEVEL OF SIGNIFICANCE:

(600)   NRHP MULTIPLE PROPERTY NOMINATION NAME:

(610)   STAFF OPINION ON ELIGIBILITY Y N U

(620)   DATE OF OPINION: (630) NAME OF STAFF MEMBER:

1348D

HP-02-23(01-29-87)