CONDITIONS SURVEY FORM Cemetery Name: Street Address: City: County: State: GPS Coordinates (x,y coordinates): Owner: Contact: Phone: Surveyor: Date: Weather (circle all that apply): hot warm cool cold dry humid sunny rain/snow/fog overcast windy IDENTIFICATION: Plot identification number: Name(s) of interred: Inscription:
Stone carver (if known):
Location of mark:
if multiple sides to the monument (e.g. column) fill out this identification for each side that has an inscription
DESCRIPTIONS: Type of interment (circle one): family family group marker individual tomb undeterminable Type of marker (circle all that apply): funeral home plaque ground marker basal bedstead cross footstone slab Woodman of the World pedestal obelisk ruin headstone pedestal column Dimensions (primary stone) Height:
Width:
Dimensions (base) Dimensions (other): Orientation (circle one):
Width: Width: East
Height: Height: North South
West
Depth (or L): Depth (or L): Depth (or L): unknown
orientation: if multiple sides you will need to designate the primary face
State of interment (circle all that apply): altered encasement fragment ruin sunken tilted standing Pedestal (circle one) : yes no Base (circle one): yes no Ornament (circle all that apply): ball cross incised decoration plaque/emblem relief decoration sculpture/statue urn vase none Furniture (circle all that apply): immortelles plaque/emblem sculpture/bench vase none Landscape (circle all that apply): concrete grass soil/dirt vegetation other Enclosure (circle all that apply): curb fence wall none Grade slope (circle one): positive negative cross-slope none Degree of grade (circle one): 0 (low) 1 2 3 (high)
Surveyor: Date: Weather (circle all that apply): hot warm cool sunny rain/snow/fog
Plot identification: cold dry humid overcast windy
MATERIALS: Check appropriate fields Type of material Primary structure Bronze Concrete Granite Limestone Marble Metal Sandstone Other:
Base
Surface Finish
Ornament
Roof
Primary structure
Base
Surface Finish
Ornament
Roof
History of Repairs Indicate repairs on the primary structure, base, ornament, surface finish and roof.
CONDITIONS: Rank conditions from 0 (low) to 3 (high) Conditions Alterations Bio-growth Collapse Cracking Disaggregation Efflorescence Erosion Exfoliation Finish detachment Fragmentation Graffiti Hard water stains Loss Open/missing joints Metallic corrosion Soiling Vegetation Other (describe):
Primary structure 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3
Base 0 0 0 0 0 0 0 0
1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2
0 0 0 0 0
1 1 1 1 1
2 2 2 2 2
3 3 3 3 3
0 0 0 0 0
1 1 1 1 1
0 0 0 0
1 1 1 1
2 2 2 2
3 3 3 3
0 0 0 0
1 1 1 1
Rank conditions from 0 (poor) to 3 (high)
Surface Finish
Ornament
Roof
0 0 0 0 0 1 2 3 0 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 0
1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3
0 0 0 0 0 0 0 0
1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2
2 2 2 2 2
3 3 3 3 3 3 0 3 3 0 0 3 3 0 3 0 3 0 3
1 1 1 1 1
2 2 2 2 2
3 3 3 3 3
0 0 0 0 0
1 1 1 1 1
2 3 2 3 2 3 2 3 2 3
2 2 2 2
3 3 3 3
1 1 1 1
1 1 1 1
2 2 2 2
3 3 3 3
0 0 0 0
1 1 1 1
2 2 2 2
0 0 0 0
2 2 2 2
3 3 3 3
0 0 0 0
3 3 3 3 3 3 3 3
3 3 3 3
Overall Condition (0=poor 3=high) Overall Integrity (0=poor 3=high)
Primary structure 0 1 2 3
0
1
0
0
1
1
2
3
Base
Roof
2
Surface Ornament Finish 3 0 1 2 3 0 1 2 3 0
1
2
3
2
3 0
1
2
3
1
2
3 0
1
2
3 0
Comments:
Original form produced by NCPTT and adapted by Utah State History