Moss, Dorothy Edith• Cemetery Call Work Sheet
Date:
Funeral Home/ Monument Company: M0
U
0
Contact Name:
Tel. #: 0 N ?Q Fax #:
Reason for call:
A-n m
4- Vag-?-?
Owner of Plot: 0 sS c?. 3?)
Interment: (One full burial and one urn, or two urns per space) _ vO--
Full Burial Urn Space x__ $30.00 Staking Fee - received on: 47
Date of Burial: Time: 'yr am/pm
Disinterment:
Deceased Name: 1-Ae S S
Date of Birth: -7 A 14'Date of Death ?;n/ 0C1
Block 7 Lot $ Space--f d
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)
6?'
Moss Feaster Funeral Home(4673) Gelco Check Number 13050721 01 3 0 5 0 7 2 1 8
693 South Belcher Road
IsSul .11L
Clearwater FL 34624 SER'°
wellsjh 6/2/2009
NOT VALID AFTER SIX 6) MONTHS FROM ISSUE DATE
ORDEROFE
Clearwater Cemetery , -_
8 Datni
112 s. Osceloa Avenue
Clearwater FL 33756
Thirty Dollars And No Cents************************************************ $ * * *30 001
NOT VALID FOR OVER 55.000 NOT REDEEMABLE FOR CASH BY DRAWER'S AUTHORIZED REPRESENTATIVE
_- __ _ _ .._ ...
SIGNATURE OF DRAWERS AUTHORIZED REPRESENTATIVE
PAYABLE THROUGH 78-858 Paul MacLaren
Fif51 PREMIER Bank 914 By signing this instrument, the aforesigned confirms that this instrument has been drawn in accordance with the authority issued by Gelco Information Network. Inc. It any
SIOUX FALLS, SD statement herein be untrue, we. the aforesigned, agree to pay the drawer upon demand the amount of this instrument and all expenses and damages arising from such misstatement.
1110 130 SO? 2 Lail' 1:09 L 408 58 51: 2 500000 6 5 Sill
slcNeR Paul MaCLareI6eRl° wellsjh
01 305C7 L:1.8
DESCRIPTION
Clearwater Cemetery
112 s. Osceloa Avenue
Clearwater FL 33756
DATE LOCATION NUMBER GL CODES CONTRACT NUMBER NAME I DESCRIPTION AMOUNT
6/2/200 4673 8405-0 467301000943 Moss - Staking Fee $********30.00