Paciorek, Myrtle (2)Cemetery CaII Work Sheet
Date: g / I1 / ao1L2
Funeral Home / Monument Company: Ross Teas -ter"
Contact Name: Pc'-' Tel. #: a- a° ° Fax #: 6 ;- a0-7 3
Reason for call: Staking Request (Interment/Disinterment) �'^{ -10 Pt-
8/0/4„
Affidavit (Burial Rights)
Monument (Marker) being placed (No fee for staking of monument)
For:
Block Lot Space
Date: / / Time:
(Send email to P&R)
Verifying Burial space
Other reason:
******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Interment: (One full burial and one urn, or two urns per space)
Full Burial ✓ Urn Space
Owner of Plot: My rile- Pa cj ore- e- I<
Deceased Name: Marto Pc e--i 0 e k-
Block 531 Lot 5° Space '-
Date of Birth: S / 31 / I `l3-gl Date of Death / i°
Date of Burial: 7/ IC/ -O 1 6
/ter
Time: ' oc) a /pm
sp4Le J4 es F.Q. `, f
3 = 14(x tZaS-24-
4 3t 9 We
$30.00 Staking Fee (Funeral Home) - received on: / /S / ?°/(=,
c (3 60
T-errwA,l # /LtS(o
Copy of permit emailed to Mark Tokar, cc: Cherise Sarnoff /P &R on: g / 16 / apt('
******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
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
,
Status of Block: 8 Lot: 50 as of 08/11/2016
1
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED PERMIT
2 FULL WALLER JAMES B 5/16/1913 07 / 31 / 1972 8/2/1972 925
3 FULL WALLER MAX L 11/1/1936 12 / 24 / 1949 12/24/1949 0
4 FULL WALLER RICHARD 1/1/1901 0
DISINTERMENTS FROM SPACE:
No Matching Records
REINTERMENTS:
No Matching Records
Page 1 of 1
LaCosse, Judith
From: Tokar, Mark
Sent: Friday, August 12, 2016 1:34 PM
To: LaCosse, Judith
Subject: RE: Cemetery Staking Request - Full Burial
Orange flags.
From: LaCosse, Judith
Sent: Thursday, August 11, 2016 11:36 AM
To: Tokar, Mark
Cc: Wells, Alexis; Sarnoff, Cherise; Vaughan, Karen
Subject: Cemetery Staking Request - Full Burial
Importance: High
Staking request for full burial received from Paul at Moss Feaster.
Name of deceased: Myrtle Paciorek
Please Stake Space 1 of Block 8, Lot 50
The date of burial will be for this coming Monday, August 15th at 2:00 p.m.
Other burials nearby in Block 8, Lot 50:
Space 2: James Waller — (full) (husband of Myrtle Paciorek)
Space 3: Max Waller— (full)
Space 4: Richard Waller — (full)
Please advise me of the color of flags being used so that we could notify the funeral home.
Thank you.
Judith LaCosse
Staff Asst
City of Clearwater
ORLS Dept.
727 -562 -4093
August 12, 2016
Attn: Paul
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: Myrtle Paciorek
Gravesite: Block 8, Lot 50, Space 1
Full Burial
Gravesite flagged with Orange flags.
Nearby Burials in Block 8, Lot 50:
Space 2 = James Waller — (full) — (husband of Myrtle Paciorek)
Space 3 = Max Waller — (full)
** 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,
Q&4L ff Lc
dith LaCosse
icial 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 Cemetery Staking Fee
BANK OF AMERICA
64- 1278 -611
i.ibU
8/11/2016 €
30.00
DOLLARS
V
VOID AFTER 180 DAYS
CHECK CANNOT EXCEED $1 ',000.00
TWO ATURES NE ; IF • ER $5,000.00
Paciorek 467_30_12Z115_03__
04 6 7 300 1 3 6011' 4061 L L 2788': 0033598100510
MOSS FEASTER FUNERAL HOME AND CREMATION SERVICES
Comments
Paciorek 467301210507
AUTHORIZED SIGNATURE
1360
L
Amount
30.00
30.00
MOSS FEASTER FUNERAL HOME AND CREMATION SERVICES 1360
L#
Comments Amount
1 Paciorek 467301210507 30.00
Total forPaciorek 467301210507 30.00
')DELUXE CORP- 1 +800- 328 -0304 www.deluxeforms.com
FDRR17 (HIKDK03 DR /1. /9M5 IR- 7 .f,7_
OFEICIAL RF(:cnu>s AND
LEGISISuivE SlRvIC Is
August 16, 2016
CITY OF CLEARWATER
Moss Feaster Funeral Home
693 South Belcher Road
Clearwater, FL 33764
To Whom It May Concern:
Po,( OFFICE BON 4748, C.LVCvvATEs, FIORIIA 33738 -4748
Crry HALL, 112 Sc )1111 OscLOLy AV E�sI F, CLE vievyx E , FLORIDA 33756
TL.LEPHONL (72 7) 562 -4090 FAN (727) 562 -4086
We received your Cemetery Staking Fee check #1360 in the amount of $30.00 for the interment
of Myrtle Paciorek in Block 8, Lot 50, Space 1.
Attached you will find receipt No. 448231.
Thank you,
) idith LaCosse
/Staff Assistant
"Eor. +L Ewpu i urvi yi An ieai pri Ewpuoy lu"
BURIAL PERMIT
CLEARWATER CARETAKER
CLEARWATER, FL
Permission is hereby granted for burial of:
Name of Deceased: MYRTLE PACIOREK
Owner of Property: MYRTLE PACIOREK &
Block : 8 Lot: 50
Date of Death: August 10, 2016
PERMIT # 1456
August 16, 2016
Burial Type: FULL
Space: 1 Date of Birth: May 31, 1928
Funeral Home Director: PAUL /MOSS FEASTER
Time: 14 :00 Staking Fee: 30.00
Date of Burial: August 15, 2016
Date Paid: August 15, 2016
Clearwater Cemetery
By ._