Stephenson, Annie Miley16 6
FUNERAL ARRANGEMENT WORKSHEET
NO
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O? AGE : g
First / Middle Last n?
ATH , ?-P Y ?- -2k 6) HOUR (?C ?d
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Arrangement Appointment-Day & Time:
O At F.H. O At Residence (Address): -
Informant interviewed by:
VITAL STATISTICS
DECEDENT'S ADDRESS
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?A -,14 2
City-Town ( State/Zip L 3375 County he
PLACE OF DEATH U' ee, ?L
City-Town State/Zip County ``
Specify: ? In-Patient ? DOA ? ER ? None
Apparent Cause of Death Length of Illness
Other Circumstances
Certifier of Death Certificate
Certifier's Address
Sex: ? M 11> Race-Ethnicity: Ct Citizen: [E-615A
BIRTHPLACE DATE OF BIRTH
Father's Name c CA His Birthplace
Mother's Maiden Name ' Her Birthplace _T?LCAC eYL
MARITAL STATUS Gw Surviving Spouse
Date & Place of Marriage
EMPLOYMENT STATUS: ? Retired (Year ) ? Presently Employed ? Not Employed
Usual Occupation p vij Al ?Ce Kind of Business Tes-dP', ?-
Employer LC No. of Years
Social Security No. S' Highest Education
VETERAN: C9-Ko ? Yes Branch of Service Rank
Service Dates to Service No.
Honors-Commendations
INFORMANT'S NAME U \ C Pk 0?
Informant's Address
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Informant's Phone % Relationship k-\-
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OWNER'S
ADDRESS
CITY OF CLEAR WATER Date: ?_z
BLOCK ? _ LOT -? SPACE_Lf)
INTERRED:
RECEIPT NO.
COST OF SPACE $??_?_
RECORDING FEE $
STAKING FEE $
TOTAL $
The Purchaser may visit the cemetery and obtain the legal description of the space selected from the Parks Staff met by appointment at the
cemetery. City Clerk Staff' may also assign spaces from the plat book The following steps shall then be followed in their listed order.
* heck availability of space
* Kepare a receipt and a copy of the
Rules and Regulation for the purchaser
Color in green plat (located in binder in overhead cabinet at receptionist's station)
* Purchaser must be present for steps. FOLLOJI/TVG STEPS ULL BE H.AADLED BY E,11PLOYEES WHO ARE ROUTINELY
RESI'O\:SIBLE l=r )P ('F,1IETF_RY RE('OR!) I F_PLV'G. IF THIS IS .A.V ,AT-;FEED PURCHASE. PLE.4SE .SEE ". 1)DIT10AAL STEPS
FORA1-.A EED (-SE OF V ACE ll;A TER.1 /E \ ; " _- T BOTTOM OF 1'. I GE.
_ Input ownership information in data base program for spaces in all Blocks. Additionally, write information in Ownership
/ Book (located in vault) for all spaces in Blocks I thru 11 only
P epare deed for each space purchased
Prepare routing memo
_
?Fi in Florida Dept. of Revenue form
Enter document information re deed in Document Tracking System
Route deed and revenue form for signature -file check list in vault (28-003)
After deed is returned to Clerk Dept. fully executed, send for recording and enter necessary information in Document
Tracking System
-Upon return of deed from recording, pull check list from 28-003, mark completed in Document Tracking System, and enter
recording date and OR Book & Page number in Cemetery data base file
-Prepare transmittal letter and enclose the original deed and a copy of the Rules and Regulations and send to owner
-File copy of deed, check list, and transmittal letter (attached in that order) in cemeteryfiles in vault by owner's last name in
28-001
ADDITIONAL STEPS FOR AT-NEED USE OF SPACE (INTERMENT)
Fill out burial permit (located in overhead cabinet at Receptionist's station)
Call Parks Field office (6139) and note Supervisor a burial has been scheduled.
Fax Burial Permit to Parks Field office (6551).
-File permit in back of blue binder located in vault above the 28-000 files
-Prepare receipt when staking fee ($30.00) is received from Funeral Home
(mark as paid in data base file and on paper copy of cemetery permit)
cmotley\notes\Cemcklst 03122100