Bartlett, Mary Alicer
•
Cemetery Call Work Sheet
Date: ? / ?,- / Or1
Funeral Home / Monument Company:
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Contact Name: Tel. #: _ (off -? Fax #:
Reason for call:
•
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a C u 1-C
Deceased Name: KA CU2-q 6-?k( P---bcLeo (tfi
Date of Birth: l? / iGilS Date of Death /
Block C? Lot I Space ls??
Owner of Plot: -
**************************************************************************************************
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:l /pm
Disinterment:
fZ;
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)
011305 21 C Branchpay0 1-(800) 444-6899 Another service of Gelco Information Network, Inc. Eden Prairie, INN 60522000 03
Moss Feaster Funeral Home (4674) 01 0 6s 6 ? 5
1320 Main Street Gelco Check Number 11806681
Dunedin FL 34698 USER ID ISSUE DATE
jenninkg 8/7/2007
NOT VALID AFTER SIX (6) MONTHS FROM ISSUE DATE
PAY TO THE
8 Sei ?rryreamres
ORDER OF City of Clearwater
112 S. Osceola Avenue oeta°=°- °k
Clearwater FL 33757
Thirty Dollars And No Cents************************************************* ***? QQ
NOT VALID FOR OVER $5,000 NOT REDEEMABLE FOR CASH BY DRAWER'S AUTHORIZED d EPRESFrJTATIVE
SIGNATURE OF DRAWERS AUTHORIZED REPRESENTATIVE
PAYABLE THROUGH 78-855 Susan Kelly
First PREMIER Bank 914 By signing this instrument, the aforesiggned confirms that this frumeni has been drawn in accordance with the authority issued by Gelco Information Network, Mrc. If any
SIOUX FALLS, SD statement herein be untrue, we, the aforesigned, agree t the drawer upon demand the amount of this instrument and all expenses and damages arising tram such misstatement.
n'0 l L80 68 L 5?i' 1:0 9Z 408 58 SI: 2 500000 6 5 Sill
SIGNER Susan Kelly USERID j enninkg 01 18066815
DESCRIPTION
City of Clearwater
112 S. Osceola Avenue
Clearwater FL 33757
DATE LOCATION NUMBER GL CODES CONTRACT NUMBER NAME / DESCRIPTION AMOUNT
8/7/200
I
i 4674 8405-0 467401000858 Mary Bartlett/staking fee $********30.00
cam; S ,i C ?? .
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