Vincent, MaryCemetery Call Work Sheet
Date: 5 / 15-1 40 i `7
Funeral Home / Monument Company: h0
Contact Name: Roh Tel. #: -7 T7 - `r`i`d 3 °6Fax #:
Reason for call: v 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) 5/61I —
Verifying Burial space
Other reason:
Interment: (One full burial and one urn, or two urns per space)
Full Burial ✓ Urn Space
Owner of Plot: P■ ar y �; 4 ,n t e vt:t
Deceased Name: IA r� V ^c v<t-
Block 14- Lot 31) Space O e-)
Date of Birth: t I / `t / 31 Date of Death S /X° / 17
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Sp 00
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Date of Burial: 5 / i K / a°1-1 Time: (1:3° ar /pm 1 0 O .) s /i-7
$30.00 Staking Fee (Funeral Home) — received on: S / i9 / a-O " CI P0Ai+ a--
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: Tuesday, May 16, 2017 8:29 AM
To: LaCosse, Judith
Cc: Wells, Alexis; Bruce, Larry; Vaughan, Karen
Subject: RE: Cemetery Staking - Full Burial
Green flags
From: LaCosse, Judith
Sent: Monday, May 15, 2017 11:11 AM
To: Tokar, Mark
Cc: Wells, Alexis; Bruce, Larry; Vaughan, Karen
Subject: Cemetery Staking - Full Burial
Importance: High
We received a call this morning from Bob of Rhodes F.H. requesting a staking for a Full burial for:
Mary Vincent in Block 14, Lot 311, Space 00 DOB: 11/4/31— DOD: 5/10/17
Other burials nearby:
Block 14, Lot 309, Space 00 = Richard Vincent
Staking is needed by this Wednesday, May 17th per funeral home.
Date of Burial: Friday, May 19th at 11:30 a.m.
Please advise me with the color of the 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
ROSALEEN A HERING
128 PLYMOUTH BLVD
SMITHTOWN, NY 11787 -2526
PAY TO THE
ORDER OF
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DATE
4071
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CHASE 0
JPMorgan Chase Bank, N.A.
www.Chase.com /�
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Back
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Burial - Transit Permit
Name First Middle Last
MARY VINCENT
Sex
FEMALE
Date of Death
05/10/2017
Age
86
If Veteran of U.S. Armed Forces,
War or Dates NO
Place of Death
6 City,Town or Village STONY BROOK
Hospital, Institution or
Street Address UNIVERSITY HOSPITAL
ii;` Manner of Death
X
Natural Cause
Accident
Homicide
Suicide
Undetermined
Circumstances
Pending
Investigation
Medical Certifier Name Title
a YOUNGZENG DING MD
•
Z
0
E^
a
Q
Nby
5
Address
101 NICOLLS RD., STONY BROOK, NY
Death Certificate Filed
City, Town or Village Brookhaven
District Number
5151
Register Number
2017001089
X
Burial
Date
05/19/2017
Cemetery or Crematory
CLEARWATER CEMETERY
Entombment
Address
CLEARWATER, FL
Cremation
Date
Place Removed
and /or Held
Removal
/ /
and /or
Hold
Address
X
Transportation
Date
05/15/2017
Point of
Shipment ISLIP MACARTHUR AIRPORT
Common
Carrier
Destination
TAMPA, FL
Disinterment
Date
//
Cemetery Address
Reinterment
Date
/ /
Cemetery Address
Permit Issued to
Name of Funeral Home GIOVE FUNERAL HOME
Registration Number
00668
Address
1000 MIDDLE CTRY RD., SELDEN, NY 11784
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above RHODES FUNERAL HOME
Address
ON CLEARWATER, FL
Permission is hereby granted to dispose of the human remains described above as indicated. ‘/\...1.-141--'
Date Issued 05/11/2017
Registrar of Vital Statistics l...
(signature)
(signature)
District Number 5151 Place Farmingville, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition / / Place of Disposition
(address)
RSE
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
(please print)
Signature Title
DOH -1555 (02/2004)
(over)
CLEARWATER CARETAKER
CLEARWATER, FL
BURIAL PERMIT
PERMIT # 1462
May 19, 2017
Permission is hereby granted for burial of:
Name of Deceased: MARY VINCENT Burial Type: FULL
Owner of Property: MARY K VINCENT & CONVERTED #312,297,298
Block : 14 Lot: 311 Space: 00 Date of Birth: November 4, 1931
Date of Death: May 10, 2017 Date of Burial: May 19, 2017
Funeral Home Director: BOB/RHODES F.H.
Time: 11 :30 Staking Fee: 30.00 Date Paid: May 19, 2017
Clearwater Cemetery
Bye. 1 u