PROBATE COURT OF MONTGOMERY COUNTY, OHIO ALICE O. McCOLLUM, JUDGE DISINTERMENT OF__________________________________________, DECEASED CASE NO. _______________________ VERIFICATION OF REINTERMENT The undersigned ______________________________________________________________ of the _______________________________________ cemetery, states that the remains of the above-named Decedent were reinterred on the ________ day of _______________, 20_____, pursuant to the Order of this Court. (Name and Title) ________________________________________ Signature ________________________________________ Typed or Printed Name ________________________________________ Cemetery ________________________________________ ________________________________________ Address ________________________________________ Telephone (include area code) FORM 25.4 ­ VERIFICATION OF REINTERMENT Effective Date: March 1, 2014 American LegalNet, Inc. www.FormsWorkFlow.com