Bjerkenes, Gladys•
Date: io / 1 s / 0 9
Cemetery Call Work Sheet
Funeral Home/ Monument Company: M ss ?ttiS-tt?
Contact Name: k--V- e- V?, ( AL v 'jel ? no fjc lc.\ It
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Tel. #: 56 a - .1070
Fax #:
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Deceased Name: (Qty,, s 3,j ?rk?? ?,-"?
Date of Birth: Date of Death / o a- /
Block 16 Lot S2 Space I I- a.
Owner of Plot: CSik-v 1 er
**************************************************************************************************
Interment: (One full burial and one urn, or two urns per space)
Full Burial
Urn Space
$30.00 Staking Fee - received on: -/-/.
Date of Burial: Time: am/pm
Disinterment:
The following authorization should be obtained prior to disinterment:
1.) A disinterment permit and burial/cremation transit permit
2.) Written authorization from the individual(s) who currently own the burial rights
for the plot; and
3.) Written authorization from the individual(s) who would be permitted to authorize burial
Monument Being Placed: (No Fee for Staking of Monument)
LaCosse, Judith
From: Tokar, Mark
Sent: Friday, June 19, 2009 7:55 AM
To: Sprague, Nicole; Taylor, Joe
Cc: LaCosse, Judith; Frith, Renee
Subject: RE: Cemetery Staking/BJERKENES
HOT pink flags were used
-----Original Message-----
From: Sprague, Nicole
Sent: Thursday, June 18, 2009 1:37 PM
To: Taylor, Joe
Cc: LaCosse, Judith; Frith, Renee; Tokar, Mark
Subject: Cemetery Staking/BJERKENES
Hi Joe,
Here is the staking I spoke to you about earlier today. The family who is requesting the staking is in
town for a couple days. They were out at the cemetery earlier today but couldn't locate the plot as
apparently the temporary marker they had out there is no longer there. If you could please stake Block
16 Lot 57 Space 1, I'd really appreciate it. I apologize for the short notice.
Thanks so much for your help!
Other burials on Block 16 Lot 57:
Space 2 - vacant
Space 3 - Stanley Szczepanski
Space 4 - "Road" (is what is in the cemetery program)
Nicole Sprague
City of Clearwater
City Clerk Specialist
(727) 562-4097
i
Cemetery Call Work Sheet
Date:
7
Funeral Home: "cJSE> Monument Company:
Contact Name: Contact Name:
Tel. #: Qq- ? ? ?? ?'-; Tel. #•
Fax #• -6 ?)- a I Fax #:
RE: K?-V'20 te`e'
S' 14. -6j, C--r fem.
Deceased Name: G-(C-cQ-"--1 S _(4 ' '5 S DOD: DOB:
Owner of Property:
Block I (- Lot 5-7 Space 4
Interment: Full Burial: Urn Space: V/
($30.00 Staking Fee) - (One full burial and one urn, or two urns)
Date of Burial: 1 / Time: am/pm
Disinterment:
The following authorization should be obtained prior to disinterment:
l.) A disinterment permit and burial/cremation transit permit
2.) Written authorization from the individual(s) who currently own the burial rights
for the plot; and
3.) Written authorization from the individual(s) who would be permitted to authorize burial
Monument Being Placed:
(No Fee for Staking of Monument)
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011305 21 C Branchpay@ 1-(800) 444-6899 Another Service of Gelco Information Network, Inc. Eden Prairie, MN 60522000 03
Moss Feaster Funeral Home(4676)
802 North Fort Harrison Avenue Gelco Check Number 11162141 O1• ?- J 1 J...
Clearwater FL 33755ISSUE DATE
gunterkm 2/1/2006
PAY TO THE NOT VALID AFTER SIX (6) MONTHS FROM ISSUE DATE
ORDER OF City of Clearwater se ddteat?res
112 South Osceola Avenue t Detals on back.
Offical Records/Karen Vaughan
Clearwater FL 33756
Sixty Dollars And No Cents************************************************** $***60.00
NOT VALIt)'F OVER $5,000 NOT REDEEMABLE FOR CASH BY DRAWER'S AUTHORIZED REPRESENTATIVE
SIGNATURE OF DRAWERS AUTHORIZED REPRESENTATIVE ._....-
PAYABLE THROUGH 78.858 William C. Stewart
First PREMIER Bank 9144 By signing this instrument, the afcres'Igned confirms that this instrument has been drawn in accordance with the author'M Issued b Gelco Information Network, Inc. If any
SIOUX FALLS, SD Y
statement herein be untrue we the aforesigned, agree to pay the drawer upon demand the amount of this instrument and all expenses and damages adsing from such misstatement.
0 L L 6 2 14 31 1((' 1:09 1,4013 58 51: 2 500000 6 5 5119
SIGNER William C. Stewart gunterkm 01 11621411
- DESCRIPTION
City of Clearwater
112 South Osceola Avenue
Offical Records/Karen Vaughan
Clearwater FL 33756
DATE LOCATION NUMBER GL CODES CONTRACT NUMBER NAME / DESCRIPTION AMOUNT
2/1/2006 4676 8405-0 Bjerkenes Staking Fee $********30.00
2/1/2006 4676 8405-0 Cassell Staking Fee $********30.00
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