Harper, William E.Date: / a"b / S
Funeral Home / Monument Company:
Cemetery Call Work Sheet
IA o SS e� �
Contact Name: Ia■ M( Tel. #: S6a� Lo? Fax #: 7 Z-- 5(,a-- ao'7,3
Reason for call: 7' Staking Request (Interment/Disinterment)
Affidavit (Burial Rights)
Monument (Marker) being placed (No fee for staking of monument)
For:
Block Lot Space
Date: / / Time:
(Send email to P&R) ✓ `I ( /(5
Verifying Burial space
Other reason:
Interment: (One full burial and one urn, or two urns per space)
Full Burial ✓ Urn Space
Owner of Plot: ``h^- C,, an. v
Deceased Name: aa. £ Net .r,
Block ! Lot 5o Space a (G
Date of Birth: It / 7 / 1 ei t t Date of Death a / a .f / ao rg
Sp a.c G
Date of Burial: 3 / 2 / (9-015
Time: 11:3 0
P
$30.00 Staking Fee (Funeral Home) — received on: 3 / -' / ,3 °!5
cLeek4t H o `t
p_ix...vz-t 4- I L,
Copy of permit emailed to Mark Tokar, cc: Cherise Sarnoff /P &R on: / /
******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
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
Revised 11/24/14
LaCosse, Judith
From: Tokar, Mark
Sent: Friday, February 27, 2015 7:51 AM
To: LaCosse, Judith
Subject: RE: Cemetery Staking - Full burial
White flags.
From: LaCosse, Judith
Sent: Thursday, February 26, 2015 10:21 AM
To: Tokar, Mark
Cc: Wells, Alexis; Sarnoff, Cherise; Vaughan, Karen
Subject: Cemetery Staking - Full burial
Importance: High
Staking request for full burial received from Dan Miller /Moss Feaster.
Name of deceased: William E. Harper
Please Stake Space 2 of Block 16, Lot 50
The date of burial will be for Monday, March 2nd at 11:30 a.m.
Other burials nearby:
Space 1: Johnnie R. Harper —full burial
Space 2: vacant
Space 3: vacant
Please advise me of the color of flags being used so that I could notify the funeral home.
Thank you.
Judith LaCosse
Staff Asst
City of Clearwater
ORLS Dept.
727- 562 -4093
February 27, 2015
Attn: Dan Miller
Funeral Home: Moss Feaster Funeral Home
Fax: 727- 562 -2073
(This fax includes a copy of Cemetery Map)
# in the circle is the Block, # in the square is the Lot
Deceased: William E. Harper
Gravesite: Block 16, Lot 50, Space 2 (C)
Full Space
Gravesite flagged with White flags.
Nearby Burials:
Space 1 = Johnnie R. Harper — (full burial)
Space 2 = vacant
Space 3 = vacant
** Staking Fee: $30.00
Please make check payable to: City of Clearwater
Mail to:
City of Clearwater
Official Records Dept. — 2nd Floor
112 S. Osceola Ave.
Clearwater, FL 33756
Please contact me with any questions.
Thank you,
Q4-a es s/.e-
dith LaCosse
fficial Records & Legislative Services
City of Clearwater
727 - 562 -4093
MOSS FEASTER FUNERAL HOME
AND CREMATION SERVICES
693 SOUTH BELCHER ROAD
CLEAR WATER, FL 33764
(727) 562 -2070
PAY TO THE
ORDER OF
City of Clearwater
- -- Thirty And 0 /100 - --
MEMO
BANK OF AMERICA
64- 1278 -611
11U4
2/27/2015
30.00
DOLLARS z
cn
VOID AFTER 180 DAYS
AUTHORIZED SIGNATURE
H 1 n 3 37 s taking_.f-ee__
II't,67300LL0411' 1:06 278/31: 0033598 LOOS Le
MOSS FEASTER FUNERAL HOME AND CREMATION SERVICES 1104
Comments Amount
Harper 467301210137 staking fee
30.00
30.00
MOSS FEASTER FUNERAL HOME AND CREMATION SERVICES 1104
L# Comments
Amount
1 Harper 467301210137 staking fee 30.00
Total forHarper 467301210137 staking fee 30.00
17) DELUXE CORP' 1 +800- 328 -0304 www.deluxeforms.com
RECEIVED
MAR 0 3 2015
CCEM L ECO OS AND
C'I5L`i''
110 nPr1F9 crvovin mnniomn rn.nn
CLEARWATER CARETAKER
CLEARWATER, FL
BURIAL PERMIT
PERMIT # 1448
March 05, 2015
Permission is hereby granted for burial of:
Name of Deceased: WILLIAM E HARPER Burial Type: FULL
Owner of Property: WILLIAM HARPER & CAROLYN HARPER
Block : 16 Lot: 50
Date of Death: February 24, 2015
Space: 2 Date of Birth: April 7, 1944
Date of Burial: March 2, 2015
Funeral Home Director: DAN MILLER/MOSS FEASTER
Time: 11 :30
Staking Fee: 30.00 Date Paid: March 3, 2015
Clearwater Cemetery
By `.