Fuentes, ConcepcionDate: ) / 5 /
Cemetery Call Work Sheet
Funeral Home / Monument Company: k0L-k-h&n4J2 44-0/1,2.
Contact Name: Bob G Tel. #: 7D-7-3 3- S 3 9.3 Fax #: 3 o L 53
Email:
Reason for call:
**
Staking Request - Interment
$30.00 staking fee (Weekdays) - $50.00 staking fee (Saturday, Sunday & Legal Holiday)
Full Burial ✓ Urn Burial _
(One full burial and one urn, or two urns per space)
Owner of Plot: M0 -to 'FLA. e_ yjte.
Deceased Name: e_o c e 6c v\
Block I5 Lot 144 Space 2. -
Date of Birth: /o / as-/ ,3 t
Date of Burial: i / / ?-' -I
**
Date of Death
Time: O; bo
_�
p
_ Monument (Marker) being placed - (No fee for staking of monument)
For:
Block Lot Space Date: / / Time:
Affidavit (Burial Rights) Verifying Burial space
Other reason:
**************************************************************************************************
y Send email to P&R to stake the space
51. -ek � , c i ,f � s& s
V Notify funeral home/monument company with color of the flags used to mark the space Let.,,, -t�►'�
Staking fee received on: - / 5 / az))) From: tt%t r k Col-% Fv
Copy of permit emailed to:
Nathan Brigman, cc: Matt Anderson, Tim Chaplinsky, Jarvis Sheeler in 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
ORLS/Cemetery/FormsPermitsTemplates/Cemetery Call Work Sheet -20
Revised 9/4/2020
► f 19-gg
Plot is staked with green flagging. South west side of cemetery.
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From: LaCosse, Judith <Judith.LaCosse@myClearwater.com>
Sent: Tuesday, January 5, 2021 9:37 AM
To: Brigman, Nathan
Cc: Anderson, Matthew; Sheeler, Jarvis; Chaplinsky, Timothy; Vaughan, Karen; Horsely, Christopher
Subject: Cemetery Staking Request - Full Burial
Good Morning,
We received a cemetery staking request this morning from Bob Grant of Rhodes Funeral Home for a full burial.
Please stake Block 15, Lot 46, Space 2 for a full burial.
Deceased Name: Concension Fuentes - DOB: 10/28/24 DOD: 1/1/2021
Note: Modesto Fuentes, the owner, is buried in Space 1.
The space needs to be marked by this Friday, January 8th at around 11:00 a.m.
(See attached burial status for Block 15, Lot 46)
Please let us know the color of the flags being used so that we could notify the funeral home.
If you have any questions please give me a call at 727-562-4093.
Thank You !!
Judith LaCosse
StaffAssistant
ORLS Dept.
727-562-4093
3
State of Florida, Department of Health, Bureau of Vital Statistics
BURIAL TRANSIT PERMIT
HE A[fl-1 DATE PRINTED: January 4, 2021 TRACKING NUMBER: 2021000984
1. DECEDENT INFORMATION
Name of Deceased Date of Death
CONCEPCION FUENTES January 1, 2021
Place of Death - County City, Town or Location Name of facility, or street address if not a facility
PINELLAS DUNEDIN MEASE MANOR DUNEDIN
Name and Address of Funeral Home/Direct Disposal Establishment Fla. Lic. No./Reg. No. Phone Number
RHODES FUNERAL DIRECTORS INC F041686 F041686 (727) 446-3055
800 EAST DRUID RD
CLEARWATER, FLORIDA, 33756
Funeral Director/Direct Disposer Fla. Lic. No./Reg. No.
ROBERT S GRANT JR F043193
Medical Verification Statement
Kat at the certifying physician's office, was contacted on 01/04/2021 by the funeral director listed above; he/she indicated that
ANDREW STEVEN GROSS, certifying physician, will complete and sign the medical certification of cause of death within 72 hours.
2. BURIAL - TRANSIT PERMIT
The Florida Department of Health, Bureau of Vital Statistics
hereby grants permission to dispose of this body in accordance with Chapter 382, Florida Statutes.
`� Permit Number: 2021-F041686-5001
�— -- Date Issued: January 4, 2021
State Registrar
3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL -AT -SEA, or HOSPITAL DISPOSITION
Authorization given by Medical Examiner District Approval Number:
4. CEMETERY OR CREMATORY
Place of Disposition: CITY OF CLEARWATER CEMETERY
Method of Disposition: BURIAL Date of Disposition:
EDRS maintains all statutorily required information regarding the death record and related
burial transit permit, therefore, returning the permit to the county health department is no
longer required.
If the Place of Final Disposition wishes to retain the copy of the permit for their file they may do so.
DH 326E, 10/12
64V-1.011, Florida Administrative Code
RECEIVE
JAN 2? 202'
OFFICIAL RECORDS A1\4,7'
LEGISLATIVE SRVCSDEPT
WORK & SON INC.
DIP ACCOUNT
(727) 577-0599
2600 GANDY BLVD
PINELLAS PARK, FL 33702
PAY TO THE
ORDER OF i `j.. �••. �-
MEMO 61 -73c -t:'..." \\},33
WELLS FARGO BANK, N.A.
WELLSFARGO.COM
THANK YOU FOR YOUR SERVICE
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