Smith, Mary FNorman, Lois
From: Norman, Lois
Sent: Thursday, October 10, 2002 10:21 AM
To: King, JoEllyn; Dacey, Louis
Cc: Perry, Glenn; Murphree, Brian; Dowd, Larry; Stephenson, Susan E.
Subject: Staking request
Please stake Block 12, Lot 75, Space 2 for an urn burial on Friday (October 11) at 3pm. The name of the deceased is
Mary F. Smith.; Moss Feaster Serenity Gardens will be conducting the service.
Thanks for your assistance.
BURIAL. PERMIT
To: Cemetery Caretaker
Clearwater, FL
Permit No.
Date:
Date of Birth:
Date of Death:
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Permission is hereby granted for burial of:
Name of deceased: F" 'S -III
Owner of Property: Marti
Space: Lot: 75' Block: Clearwater Cemetery.
Funeral Home: M05s reash? Funeral Director: ?f e-n r ?+^
3 (AM6)
Date of Burial: /0- It- 0-1- Time:
Staking Fee $ 30. U Paid Date: l o - ?o- ?,tr CITY OF CLEARWATER
(lb/dbf/plat/call 6579 & fax to 6577 & 6551 (Parks & Rec) By: altl '
ALSO EMAIL TO: JoEllyn King, Glenn Perry, Lou Dacey and Larry Dowd
COR-0009 (11/00)
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City of Clearwater, Florida
City Clerk Department
Phone (727) 562-4090
Fax (727) 562-4086
FAX MESSAGE
TO: Peri Craven
LOCATION: Moss Feaster
FAX NO.: 562-2082
COMMENTS: Reference: Mary F. Smith
Block 12, Lot 75, Space 2, Clearwater Municipal
Cemetery
Staking Fee is $30.00; make check payable to City
of Clearwater
Map is attached showing location of Block 12, Lot
75
FROM: Lois Norman, (727-562-4091)
DATE: 10/01/02
NUMBER OF PAGES THIS MESSAGE (INCLUDING THIS PAGE): 2
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COMMONWEALTH OF VIRGINIA - CERTIFICATE OF DEA
DEPARTMENT OF HEALTH - DIVISION OF VITAL RECORDS - RICHMOND
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REGISTRATION CERTIFICATE STATE FILE
FOR DIVISION OF
VITAL RECORDS AREA NUMBER NUMBER j?
/Y NUMBER
<
DECEDENT 1. FULL NAME (first) (middle) (last) 2. SEX male female
OF DECEDENT
Barbara H arris Smith ?
3. DATE OF (mo.) (day) (year) 4. AGE IF UNDER 1 YEAR IF UNDER 1 DAY 5. DATE OF (mo.) (day) (year) 6. WAS DECEDENT
yes no
DEATH ) - - - - - -s- -h - - - r - - - -
months 1 dayours 1 minutes BIRTH EVER IN U.S.
ARMED FORCES? El
June 3, 2002 79 years Jul 3 1922 ?-1
PLACE OF 7. NAME OF HOSPITAL OR INSTITUTION OF DEATH (if none, so stale) I Out Pat. 8. COUNTY OF DEATH (if independent city, leave blank)
DEATH 1
1 DOA Emer Rm Inpatient
Fair Oaks Hospital ? U ? Fairfax
9. CITY OR TOWN OF DEATH inside city or town limits? 10. STREET ADDRESS OR RT. NO. OF PLACE OF DEATH
yes no
Fairfax ? 11 3600 Joseph Siewick Drive
USUAL 11. STATE (OR FOREIGN COUNTRY) OF DECEDENT'S RESIDENCE 12. COUNTY OF DECEDENT'S RESIDENCE (it independent city, leave blank)
RESIDENCE
OF DECEDENT Virginia Fairfax
T1 CITY OR TOWN OF RESIDENCE inside city or town limits? 14. STREET ADDRESS OR RT. NO. OF RESIDENCE I ZIP CODE
yes no
Fairfax ? ZI 12512 Chronical Drive 22030
PERSONAL 15. NAME OF DECEDENT'S FATHER 16. MAIDEN NAME OF DECEDENT'S MOTHER
DATA OF
DECEDENT Lemuel Harris Sallie Boyd
17. RACE OF DECEDENT 18. OF HISPANIC ORIGIN? If yes, specify Cub an, Mexican, 19. EDUCATION (Specify only highest grade completed)
Pueno Rican, etc. II??n0 El
es 12
Caucasian `-k y Elementary/Secondary (0-12)
College (1-,t or 5 +)
20. CITIZEN OF WHAT COUNTRY 21. BIRTHPLACE (state or country) 22. NEVER MARRIED ? DIVORCED ? 23. IF MARRIED OR WIDOWED, NAME OF SPOUSE
(if divorced leave blank)
A
U
S Florida ? Arthur Edward Smith
Jr
.
.
. MARRIED WIDOWED ,
.
24. SOCIAL SECURITY NUMBER 25. USUAL OR LAST OCCUPATION 26. KIND OF BUSINESS OR INDUSTRY - 27. INFORMANT - OR SOURCE OF INFORMATION
226-84-2832 Homemaker Arthur Edward Smith Jr.
28. PART I. Enter the diseases, injuries, or complications that caused the death. D tl r th
e of dying, suc s cardi c or respiratory arrest. shock, or head failure. INTERVAL BETWEEN
CAUSE OF DEATH List only one cause on each line. • ONSET AND DEATH
c Z
f
c
IMMEDIATE CAUSE (Final disease or (A) r ' t v " N
TO condition resulting in death) DUE TO (OR AS CONSEQUENCE O l'):
PHYSICIAN:
lete and
Com Sequentially list conditions, if any, leading (B)
p
sign medical to immediate cause. Enter UNDERLYING DUE TO (OR AS A CONSEQUENCE OF):
certification CAUSE (Disease or injury that initiated
(item 28) and events resulting in death) LAST
return both C
copies to funeral z PART 11. Other significant conditions contributing to death but not resulting in th e underlying cause given in Part 1. 28a. AUTOPSY? yes no
director as soon
s
ibl
after O AUTHORIZED BY:
11 ?
as po
s
e f-
determination of t,
cause. LL 28b. IF FEMALE, WAS THERE A PREGNANCY 28c. IF EXTERNAL CAUSE, IT WAS 28d. DESCRIBE HOW INJURY RELATING TO DEATH OCCURRED
¢ IN PAST 3 MONTHS? PRIMARY Q or CONT RIBUTING ?
NOTE: if W
U
yes ? no E1 unknown E] TO CAUSE OF DEATH
"Pending" must Q 28e. TIME OF INJURY (mo.) (day) (year) 28f. INJURY OCCURRED 28g. PLACE OF INJURY (home, farm, 128h. (city or town) (county) (state)
be indicated, so U factory, street, office bldg., etc.) I
state in part 1
and notit O
W
A.M.
while
not while
?
I
y
f fi
l f P.M. at work at work I
registrar o
na
decision as soon 28i.
as possible. To the best of my knowledge, deat rred at (a.m.) (p.m.) on the date and place and from the cause(s) stated.
_______________ ___---__
ACTUAL ____--_-_____-__--___________ __ -_ ________
I DATE SIG ED
S GNATURE 1 ( l??
________________________________
_____________ ____
_
i
NAME OF ATTENDING PHY51_ __ __ AN (Ty Print) ADDRESS OF ATTENDING PHYS_ICIAN_ - _ _ _ _ _ _ _ _ _ _ _ _ _
?? rU I_
?,Ik OZq FI 'fax VR.024 =
FUNERAL 29. BURIAL REM AL CR ATION 30. PLACE (name of cemetery or crematory) (city or county) (state)
DIRECTOR OF BURIAL,
1
? ? REMOVAL, ETC. Arlington National Cemetery Arlington, VA
f funeral director or person legally filin this certificate)
31. NAME OF
UNERAL Ever l
Funeral Home
y
H
OME AND
M ADDRESS: 10565 Main St Fairfax, VA 22030
REGISTRAR 32. (signature of registrar) DATE RECORD
FILEO:
cnvcu
'S U
GISTRAR'S USE V
This is to certify that this is a true and correct reproduction of
the original record filed with the FAIRFAX COUNTY HEALTH DEPARTMENT,
FAIRFAX VIRGINIA.
JUNE 11, 20_02
DATE ISSUED _ DEPUTY REGISTRAR
(SEAL)
VOID IF ALTERED OR DOES NOT BEAR IMPRESSED SEAL
LF205-04
GENERAL POWER OF ATTORNEY
(With Durable Provision)
NOTICE: THIS IS AN IMPORTANT DOCUMENT. BEFORE SIGNING THIS DOCU-
MENT, YOU SHOULD KNOW THESE IMPORTANT FACTS. THE PURPOSE OF THIS
POWER OF ATTORNEY IS TO GIVE THE PERSON WHOM YOU DESIGNATE (YOUR
"AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY
INCLUDE POWERS TO PLEDGE, SELL OR OTHERWISE DISPOSE OF ANY REAL
OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL
BY YOU. YOU MAY SPECIFY THAT THESE POWERS WILL EXIST EVEN AFTER
YOU BECOME DISABLED, INCAPACITATED OR INCOMPETENT. THIS DOCUMENT
DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL OR OTHER HEALTH CARE
DECISIONS FOR YOU. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO
NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU. YOU
MAY REVOKE THIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO.
TO ALL PERSONS, be it known that I, 9 P, T1-f ()P, E 6-1-L T t-(, :S r .
of 16.2-44 (.(EYS 10 A(E CO-P'kT, C1.CAr2Wn'r EFL , F4 33
the undersigned Grantor, do hereby make and grant a general power of attorney to c5,+1 . A-Y S. J 1_O H i1
of
/6.2-41 Kr?./5-ro,4E c'oug7' C?1?te aT , ;_? 33"?St;
and do thereupon constitute and appoint said individual as my attorney-in-fact/agent.
My attorney-in-fact/agent shall act in my name, place and stead in any way which I myself could do, if I
were personally present, with respect to the following matters, to the extent that I am permitted by law to act through
an agent:
(NOTICE: The grantor must write his or her initials in the corresponding blank space of a box below with respect
to each of the subdivisions (A) through (O) below for which the Grantor wants to give the agent authority. If the blank
space within a box for any particular subdivision is NOT initialed, NO AUTHORITY WILL BE GRANTED for mat-
ters that are included in that subdivision. Cross out each power withheld.)
[ ] (A) Real estate transactions
[ ) (B) Tangible personal property transactions
[ ] (C) Bond, share and commodity transactions
[ ,7A] (D) Banking transactions
[ ] (E) Business operating transactions
[ ] (F) Insurance transactions
[ ] (G) Gifts to charities and individuals other than Attorney-in-Fact/Agent
(If trust distributions are involved or tax consequences are anticipated, consult an attorney.)
1992-2001 E-Z Legal Forms, Inc. Page I Rev. 03/01
This product does not constitute the rendering of legal advice or services. This product is intended for informational use only aad is not a substitute for legal
advice. State laws vary, so consult an attorney on all legal matters. This product was not necessarily prepared by a person licensed to practice law in your state.
[ ']
[ ",to
]
[ ]
[( ]
[ ?, ]
-}---- (H) Claims and litigation
(I) Personal relationships and affairs
(J) Benefits from military service
(K) Records, reports and statements
(L) Full and unqualified authority to my attorney-in-fact/agent to delegate any or all of the fore-
going powers to any person or persons whom my attorney-in-fact/agent shall select
(M) Access to safe deposit box(es)
---(--fie autd?erz? medical and surgical pr?P?li,rPs?Pennsylvania only}
] (O) All other matters
a
[] Durable Provision:
(P) If the blank space in the block to the left is initialed by the Grantor, this power of attor-
ney shall not be affected by the subsequent disability or incompetence of the Grantor.
Other Terms:
My attorney-in-fact/agent hereby accepts this appointment subject to its terms and agrees to act
and perform in said fiduciary capacity consistent with my best interests as he/she in his/her best
discretion deems advisable, and I affirm and ratify all acts so undertaken.
TO INDUCE ANY THIRD PARTY TO ACT HEREUNDER, I HEREBY AGREE THAT ANY THIRD
PARTY RECEIVING A DULY EXECUTED COPY OR FACSIMILE OF THIS INSTRUMENT MAY
ACT HEREUNDER, AND THAT REVOCATION OR TERMINATION HEREOF SHALL BE INEF-
FECTIVE AS TO SUCH THIRD PARTY UNLESS AND UNTIL ACTUAL NOTICE OR KNOWLEDGE
OF SUCH REVOCATION OR TERMINATION SHALL HAVE BEEN RECEIVED BY SUCH THIRD
PARTY, AND I FOR MYSELF AND FOR MY HEIRS, EXECUTORS, LEGAL REPRESENTATIVES
AND ASSIGNS, HEREBY AGREE TO INDEMNIFY AND HOLD HARMLESS ANY SUCH THIRD
PARTY FROM AND AGAINST ANY AND ALL CLAIMS THAT MAY ARISE AGAINST SUCH
THIRD PARTY BY REASON OF SUCH THIRD PARTY HAVING RELIED ON THE PROVISIONS OF
THIS INSTRUMENT.
Signed u er seal this day of `)Y1 (?(??(year).
t
Signed i nce o
tnf ?- Grantor may//JJ/ _
i ess Attorney n-Fac Agent
State of U i ? K X CA-, 1
County of 1' (%L, c 1? Cti-?_ f _
On before me, 1 1? 4 Gti_ h t 0 a f- y , appeared
` , personally known
to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capac-
ity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the
person(s) acted, executed the instrument.
WITNESS my hand and rofffiFea.
Signatu
t' _31 _0i
Affiant Known Produced ID
Type of ID
(Seal)
Page 2
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