Adams, Jack WClearwater
City of Clearwater, Florida
Official Records and
Legislative Services Department
Phone (727) 562-4090
Fax (727) 562-4086
FAX MESSAGE
TO: JoEllyn King/Brian Murphree
LOCATION: Parks and Rec
FAX NO.: 4825 and 6551
COMMENTS: This is the Burial Permit information for Jack
Adams; funeral scheduled for Friday, April 16,
2pm. You have already sent the email re purple
flags. This is info for your records. If you need the
permit number, we will have that after we enter the
info into the program.
FROM: Lois Norman, (727-562-4091)
DATE: 4/15/2004
NUMBER OF PAGES THIS MESSAGE (INCLUDING THIS PAGE):
1"V ` 1--IloN
C
2
j---- tr, 11
1440 yµ.
BURIAL, PERMIT
To: Cemetery Caretaker Permit No.
Clearwater, FL Date: 4 -
Date of Birth: 14 / - /q33
Date of Death: 4 -,2 - aoo4
Permission is hereby granted for burial of
PLEASE CHECK ONE (Very Important) URN_ ? FULL
Name of deceased: Jkc,k W Ak-,n5
Owner of Property:
Space:
Lot:
Funeral Home: CJea.rwJ.-r (-un-r Ifo-,,-e- Funeral Director
Date of Burial: Feel - Time: ;tl
Staking Fee $ 80 •':T Paid Date:
Clearwater Cemetery.
?,ivi d ?G? n ?•Ll (e ? n
(AM(a
CITY OF CLEARWATER
(lb/dbf/plat/call 6579 & fax to 4825 & 6551 (Parks & Rec) By: 4 ' -
ALSO EMAIL TO: JoEllyn King, Bett-Btteey Brian Murphree (cell if needed 224-7105)
SAProceduresTurial Permit.doc (11/02)
Block:
Clearwater
City of Clearwater, Florida
Official Records and
Legislative Services Department
Phone (727) 562-4090
Fax (727) 562-4086
FAX MESSAGE
TO: Clearwater Funeral Home
LOCATION: Belcher location
FAX NO.: 733-3501
COMMENTS: See attached map for Block 11, Lot 33. I have
asked the Parks and Recreation Department to stake
the space and let me know what color flags they
have used. Will call with information when
provided.
FROM: Lois Norman, (727-562-4091)
DATE: 4/13/2004
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FLORIDA DEPARTMENT OF k
State of Florida, Department of Health, Vital Statistics
HjXj7
APPLICATION FOR BURIAL - TRANSIT PERMIT
A. (TYPE)
1. Name of First Middle Last Date Month Day Year
Deceased of
lack \A/ AADeath A-- n nnnw
2. Place of Death City, Town or Location Name of (If neither, give street address) '
County Hosp. or
Pinellas Inst. Com r
3. Name of Medical Address one Number
Certifier Abdul S. Khan, MD 7
1742 Drew Street
Medical Examiner Physician 727-447-5454
4. Name of Funeral Home/Direct Disposal Address ' a. icc o./Reg. No. Phone No. (Area Code)
Establishment 2966 Belcher Road
Clearwater Funeral Homes
5. Check a. ? The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. 1-1 was contacted on
He/s eve at hts ea h wa r ht causes, that there was no accident nor of a ezterrla cause of death,
and that will complete and sign the medical
an ME) certification of cause of death wit in 7 Hours. '
C. ?
was contacted on
medical certification of cause of death within 72 hours.
6. Funeral Director! ? Sgna F.E. No./Reg. No.
Direct Disposer V L a-Y14 97
B. BURIAL - TRANSIT PERMIT
He/she verified that
Medical Examiner, will complete andsign-the:
Date Signed
Permission is hereby granted to dispose of this body. Permit No.
A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physic-Whas
been contacted by the funeral director and will not be able to complete the medical certification of cause-of-death section of the death certificate within
72 hours.
F?No extension of time for filing the death certificate has been requested.
Registrar or ?j Date Date Certificate
Subregistrar Signature ?-Issued: Apr 619004 Due: r 7 2004
C. AUTHORIZATION for`16REMATION, DISSECTION, or BURIAL-AT-SEA
Approval Number. Date U
Me ical Examiner,
gave authorization by telephone to _
C/ ej
Funeral Director/Direct Disposer. Date T
The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiin erior&of 4 ` i rs after death is
required for all cremations.
D. FOR FUNERAL DIRECTOR/DIRECT DISPOSER USE ONLY
1. Date Burial-Transit Permit (pink copy) was filed with Local Registrar
2. Date Temporary Certificate was filed with Local Registrar:
3. Date Permanent Certificate was filed with Local Registrar:
5. Name and place of disposition:
6. Funeral Director/Direct Disposer Report Filed: Yes
No Date Filed:
FUNERAL DIRECTOR/DIRECT DISPOSER COPY
DH 326, 8197 (Obsoletes all previous editions)
(Stock Number 5740-000-0326-2)
2165
CLEARWATER FUNERAL HOME AT BELCHER, INC. AN6OM* BANK
d/b/a ABBEY PARKLAWN FUNERAL HOME THE RELATIONSHIP PEOPLE'
2966 BELCHER ROAD 63-4661631
DUNEDIN, FL 34698 5!14/2004
(727) 733-2300
$ **30.00
PAY TO THE of Clearwater
ORDER OF City
Thirty and 00/100*********************************************************************************************s****** DOLLARS
City of Clearwater
4551
MEMO:
Staking fee - Jack Adams
Il'00 2 1 6SIl' 1:063 L046681: 79670046871i'
of -fit , aan?,
4,
0/0 - 00000 -
000 - 4400
SUNCOAST CREMATORY
2966 BELCHER ROAD
DUNEDIN, FLORIDA 34698
(727) 733-2300
CERTIFICATE OF CREMATION
It is hereby certified that this receptacle contains the cremated remains
of: Jack W. Adams
Date of Death: April 2, 2004
City of. Clearwater , County of:
Pinellas
State of Florida; and that the cremation took place at our facility on,
Date: April 7, 2004
Permit # 403
Charles Scalisi; Licensed Funeral Director