Form 1

Application for Permit to Restore & Reproduce Gravestones

(See detailed instructions)

Organization Date

Address

Contact Phone

Cemetery Location

Owned or Controlled by Size

Earliest Gravestone Before 1885 Designated Landmark (Yes) (No)

Cemetery Condition

Proposed Work: (General Cleanup) (De-soil) (Replant) (Clean Stones) (Repair Stones)

Other

City or Town Acceptance of enabling Act, St. 1973, c. 272, § 73A

Date

Project approval, Coordination, and Participation:

City or Town Historical Commission Owner

Technical Assistance From

Form 1. (continued)

Project Funded by Total

In Hand Contributions From Total

Project to Start Completion Date

Attachments

1. (1) Description of organization, including membership, governance, non-profit status, etc.
2. (2) Statement of Historical significance of Cemetery.
3. (3) Statement of Acceptance and Approval of Project by Owner or Controlling Agency such as Town, Council, etc.
4. (4) Statement of Work Plan and Financial Plan and Budget.
5. (5) Listing of Local Resource People and their Part in Project.
6. (6) Statement from School Systems Indicating Role of Schools and Students in Project if any.
7. (7) Official Statement of City or Town Acceptance of the Enabling Act Allowing Restoration.
8. (8) Statement from Supporting Agencies Indicating Extent of Financial Support, Real or in Kind.

Official Use Only

Approval:

Organization Project Resources

Competence Coordination

Approved

Secretary of the Commonwealth

DIRECTIONS FOR COMPLETING APPLICATION FORM

Organization: Give name of applicant organization

Contact: Name of person to contact concerning proposal

Cemetery: Give name of cemetery

Size: Give dimensions of cemetery

Owned or controlled by: Give name of owner of cemetery or town agency that has authority to provide access and approval for restoration project

Earliest gravestone: Give earliest known or recorded date

Before 1885: Total number of stones dated before 1885

Designated landmark: Is cemetery a designated landmark of the Mass. Historical Commission, (yes) (no)

Cemetery condition: Indicate whether cemetery is abandoned, overgrown, vandalized, etc. and how many stones are broken or missing

Proposed work: Circle all restoration tasks you are planning to undertake

City or town acceptance of enabling act: city or town must give date of acceptance

Project approval: Indicate by check mark which agencies have approved project

Project funded by: Give name of agencies, foundations, or persons providing funds and give total

Technical assistance: Give name of persons or organization who will provide technical assistance to project

In kind contributions: List agencies, organizations, or individuals making substantial in-kind contributions (sweat equity) to project and estimated total value

REGULATORY AUTHORITY

950 CMR 41.00: M. G. L. c. 272, § 73A.