A record shall be kept by each corporation organized under this act, of the rights of burial disposed of by such corporation, in the following form:
   No. The ………. for ………., to them paid by ………., of ………., hereby grant unto ………. right of burial in their grounds, and embracing in reference to this map, ………., subject, nevertheless, to assessment and forfeiture, as provided by law.
   Dated, ……………….. 18….. .
   Countersigned, ………., President. ………. Clerk.