Anderson, Karen Fw
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Cemetery Call Work Sheet
Date: 5 /,? / os
Funeral Home/ Monument Company: 00 S F -5 ?
Contact Name:
In ..
Tel. #: ;5&A - ,I?ofr Fax #:
Reason for call:
Deceased Name: ?c-E-U, }- . A fS2 -BK
Date of Birth: A-/TT/ fK Date of Death / / aO® g
• Block i ?D Lot __(0 Space
Owner ofPlot******ftP hP hI'O* ??fta")** Iefdu**** ued
Interment: (One fu// burial and one urn, or two urns per space)
Full Burial Urn Space
$30.00 Staking Fee - received on: 1--/-A-/?9 tl-
Date of Burial: / Xry o Time: _ I I : 0 m 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)
I /
011305 21 C Branchpayrg) 14800)444-6899 Another service of Gelco Information Network, Inc. Eden Prairie, MN 6052?000 03
i Moss Feaster Funeral Home(4673) Gelco Check Number 12317594 s
"n -P 4
93 South Belcher Road Q1 x 01 .r
6
Clearwater FL 34624
USEH ID ISSUE DATE
cretorssn 5/9/2008
PADTOTHE City of Clearwater NOTVALID AFTER SIX (6) MONTHS FROM ISSUE DATE
OR OF s ry?
100 South Myrtle Avenue # 210 L° D nr et?„"'s
Post Office Box 4748
Clearwater, FL 33758
f
Thirty Dollars And No Cents************************************************* $***30.00
/A NOT VALID FOR OVER $5,000. NOT REDEEMABLE FOR CASH BY DRAWER'S AUTHORIZED PEPRESF_NI Al WE
' SIGNATURE OF DRAWERS AUTHORIZED REPRESENTATIVE
PAYABLE THROUGH Philip ray
First PREMIER Bank 78-858
gj qq By signing this instrument, the egred confirms that this instrument has been drawn accordance with the authority issued elco Information Network, Inc. If any
SIOUX FALLS, SD statement herein be untrue, we, , the aforesigned, agree to pay the drawer upon demand the amount of this instrument t and all expenses and damages arising from such misstatement
ii'0 L 23009440 1:09 1,408585I: 25000006SS110
SIGNER Philip Gray U3EH? cretorssn
DESCRIPTION
City of Clearwater
100 South Myrtle Avenue # 210
Post Office Box 4748
Clearwater, FL 33758
01 231 75944
DATE LOCATION NUMBER GL CODES CONTRACT NUMBER NAME / DESCRIPTION AMOUNT'
5/9/2008 4673 8405-0 467301000698 Staking Fee for Anderson $********30.00