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London, Friedadam' 2 Cemetery Call Work Sheet ,0\r Date: CxP L Funeral Home / Monument Company. r??r Contact Name: Tel. #: 3S? 1?5 ©l l I Fax #:}, Reason for call: "tc> ..Yi- z Deceased Name: Date of Birth: /a 3/ ? Date of Death j q/ (Av Block Lot Sp cc l y • _,r??,?.? e, C .. Owner of Plot: ************************************************************************************************** Interment: (One full burial and one urn, or two urns per space) L Full Burial Urn Space $30.00 Staking Fee - received on: Date of Burial: -I/ Pe Time: a m ********************************************************************** ********************** 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) 0 •,. • Date: B / 15-/ «? Cemetery Call Work Sheet Funeral Home/ Monument Company: Contact Name: U a-Q- (L w l t'• c?w,? Tel. #:( 5 a>??? b Fax #: Reason for call: L??'z-? -?''??' ?'Y---fir ?? ??- .?' --? ? (t -?- V..< < -??,r?--•? -}-J 1/???-L --?? _ Deceased Name: t QCL- r c- l Date of Birth: Date of Death • Block Lot Space 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: 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) 0 • ATTN: Richard Brown / Brown's Funeral Home This fax includes a map of the Clearwater Municipal Cemetery. Deceased: Frieda London Gravesite: Block 2 / Lot 4 / Space 24 Full Space - vacant at present Gravesite will be flagged by Friday, August 17th. (orange flags) Full Burial to take place Monday, August 21 st at 10:00 a.m. ?O Staking Fee: $30.00 Please make check payable to: City of Clearwater Mail to: City of Clearwater • Official Records Dept. 112 S. Osceola Avenue Clearwater, FL 33756 Please contact me with any questions. Thank you, Karen Vaughan Official Records & Legislative Services 727-562-4091 0 ?Er0 Y Awful • STREET L.L' fa.'.?I W Fl L-A A m ° f MI N N N N ly CJ • ?....> 1 rq-: N - ]L °1 ^? = t7 l.- W O U m t a 1 N 1 ^ ? A O 10 h f A N - '? 7 M N ? t • N n ? 2 3 -- 4 _• a o -7 '? n ? n r r rn N • r N t• ,N N N N A ? - - N N N N N ? r ? ? O N N N N Mf.. M Iq p Iq r1 o M N OI t0 M1 MI F ^ ° M N r co 10 of O ry M n v = r a -C5> In m m m E-- N A ? m UD r In. n f F _ I N M yryj ? ?t a TUSKAWILLA ?3?fr N O rn N Y. M m LL r °C yW ¢cr N} U O co N co ?co LLI LL E (,?= V W(raTo ?QO9 OrPU a? U- rZ CCJ at U M o Q N ? Z cm U. 0 Lo z. ?O Oa m W ' ?0 0 oC rW Y0 aEr a0 Ln -a CS C? co O O O S a a O 1 l rn a O .a rri cJ3 O 1 ru O Ln O O ¦ ca v LL f DEPARTMENT OF i State of Florida, Department of Health, Vital Statistics APPLICATION FOR BURIAL - TRANSIT PERMIT A. (TYPE) 1. Name of First Middle Last Date Month Day Year Deceased of Freida M. London Death August 14 2006 2. Place of Death City, Town or Location County Alachua Gainesville Name of Hosp. or Inst. (If neither, give street address) North Florida Regional Medical Center 3. Name of Medical Address Phone Number Certifier Osvaldo Rodriguez, M.D 4343 W. New berry Road, Suite 12 Medical Examiner Physician 4. Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No. (Area Code) Establishment P.O. Box 2172 Brown Funeral Home & Cremato C stal River Florida 34423 1770 352-795-0111 5. Check a. The medical certification has been completed and signed. A completed certificate of death accompanies this Appropriate application. Box q? b. was contacted on He/she verified that this death was from natu I cau s, that there was no accident nor other external cause of death, and that will complete and sign the medical certification of cause of death within 72 hours. C. F-1 was contacted on He/she verified that , Medical Examiner, will complete and sign the medical certific se of death within 72 hours. 6. Funeral Director/ Si re n"l F.E. No./Reg. No. Date Signed Direct DisposerRichard T. Brown 2840 8/21/2006 B. BURIAL - TRANSIT PERMIT rmission is hereby granted to dispose of this body. Permit No. 156-1770-06 A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has been contacted by the funeral director and will not be able to complete the medical certification of cause-of-death section of the death certificate within 72 hours. [:]No extension of time for filing the death ificate has been quested. Registrar or Date Date Certificate Subregistrar Signature ued: 8/21/2006 Dye: C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA Approval Number: Date Medical Examiner, , gave authorization by telephone to Funeral Director/Direct Disposer. Date The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting period of 48 hours after death is required for all cremations. D. CEMETERY OR CREMATORY, Method of Disposition: Place of Disposition /«i /'( G(G(/ C C'01+:1G _T BURIAL FISTORAGE Date of Disposition Z i '- CREMATION Signature of Sexton t or Person-in-Charge J} OTHER (Specify) This permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton) and returned within 10 days to the local County Health Department in the county where disposition occurred. Distribution: Whits: Cemetery or Crematory DH 326, 6197 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer (Stock Number: 5740-000-0326-2) Pink: Local Registrar eR7-d G