Shepherd, Mary C•
Date: `7 /V/ ID
Cemetery Call Work Sheet
Funeral Home/ Monument Company:
Contact Name: JW "LAC S '-->
U
Tel. #: r Ac? 1 Fax #:
Reason for call: 51-a it-(cm i.,e,:, t
Deceased Name: '()An(
Date of Birth: Date of Death ? /,9(4?' / 10
•
Block Lot .
Space ?
Date of Burial: I /-3()-/ Q Time: 3:0,9 a pm
**************************************************************************** ******************
Disinterment:
Owner of Plot:
**************************************************************************************************
Interment: (One full burial and one urn, or two urns per space)
C-P? -t, ?dc T i ??
Full Burial Urn Space n pd- A
$30.00 Staking Fee - received on: 7 /--30 1:7-1 -ati - -r- 711, 0/° ?Y/0)
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)
FLORIDA DEPARTMRNT OF
HEALT
A. (TYPE)
1. Name of First
Deceased Mary
Middle Last
Shepherd
Date Month Day Year
of July 27, 2010
Death
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Pinellas Clearwater Inst. Belleair Health Care Center
3. Name of Medical Address Phone Number
Certifier Babu Paladugu, MD 9555 Seminole Blvd., X6205
Medical Examiner XX Physician Seminole, FL 33772 (727)319-8900
4. Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment 4945 East Bay Drive
National Cremation Society Clearwater, FL 33764 FO 40341 (727)536-0494
5. Check a. ?
Appropriate
Box
b. Pq
c.
The medical certification has been completed and signed. A completed certificate of death accompanies this
application.
Deanna was contacted on 7/27/10
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. Paladugu will complete and sign the medical
certification of cause of death within 72 hours.
was contacted on
of cause of death within 72 hours.
He/she verified that
Medical Examiner, will complete and sign the
6. Funeral Director/ natt Flo./Reg. N;? Date Signed
Direct Disposer r") l? 2,14 ! 7/27/10
B. V V v BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this Permit No. 10-40341-735
10 A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has
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 Date Date Certificate
Dye: 8/ 6/ 10
p? f/? Issued: 7/27/10
Subregistrar Signature
2.2
cf
JAA
C.
Approval Number:
AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA
Date
Medical Examiner, , gave authorization by telephone to
Funeral Director/Direct Disposer. Date
The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting period of 48 hours after death is
required for all cremations.
D. CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition Clearwater Cemetery
Clearwater, FL
El BURIAL STORAGE Date of Disposition
OCREMATION OTHER (Specify) RECWED
Signature of Sexton t AUG 0 4 2010
or Person-in-Charge
This permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Director/Direct Disposer whe aft{ ed
within 10 days to the local County Health Department in the county where disposition occurred. MISLATNE $RVC$ DEPT
Distribution: White: Cemetery or Crematory
DH 326, 6/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number: 5740-000-0326-2) Pink: Local Registrar X-w `0 Pw
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
National Cremation Society(2787) Gelco Check Number 13197714 01)
4945 East Bay Drive
Clearwater FL 33764 - - - USER ID - ISSUE DATE_
cranerml 7/28/2010
PAY TO THE NOT VALID AFTER SIX (6) MONTHS FROM ISSUE DATE
ORDER OF City of Clearwater
PO Box 4748 8 $ee,aiiGUl",Ibl"17
Ds on back.
Clearwater FL 33758
Thirty Dollars And No Cents******************** ************************* $***30.00
A?n. R OVER $5,000 NOT REDEEMABLE FOR CASH BY DRAWER'S AUTHORIZED REPRESENTATIVE
RE: NIGr
Shc crca fstatement _--__-.___w--.__ _TURE OF DRAWERS AU_THO REPR E ____._.._RIZED --__-_N _._NTATIVE
PAYABLE THROUGH 78-858 y MyFirst PREMIER Bank 914 instrumentthat this instrument has bean drawn in
SIGNA accordance with the authority issued by Gelco Inlormation Network, Inc. If any
SIOUX FALLS, SD in be untru ree to pay the drawer upon demand the amount of this instrument and all expenses and damages arising from such misstatement.
+!10 13 19 ? 7 14 3110 1:09 1408 58 51: 2 5000006 5 S0
I3?o?
0 (0
BURIAL PERMIT
CLEARWATER CARETAKER
CLEARWATER, FL
Permission is hereby granted for burial of:
Name of Deceased: MARY SHEPHERD
PERMIT # 2616
August 02, 2010
Burial Type: FULL
Owner of Property: JAMES W SHEPHERD & MARY C WASHINGTON
Block : 14 Lot: 538 Space: 1 Date of Birth: December 10, 1916
Date of Death: July 26, 2010 Date of Burial: July 30, 2010
Funeral Home Director: JEFF MYERS - NATIONAL CREMATION
Time: 15 :00 Staking Fee: 30.00 Date Paid: July 30, 2010
Clearwater Cemetery nn
By u 12?
Cemetery Call Work Sheet
0
Date:
Funeral Home / Monument Company: em ket ?r Md? k?e?rt L.i sc okkI'
Contact Name: c7e?h-
Tel.#: g13- 663- 0510 Fax #: 813 663- OS 1a.
Reason for call: e u. Qw.-C-.:. Q -to Pd- fL
Deceased Name: MCcrl
Date of Birth: Date of Death '7 / X -7 / l o
Block Lot 538 Space i'
Owner of Plot:
Interment: (One full burial and one gji?,two urns per space)
Full Burial / Urn Space
$30.00 Stakiugfee - received on: / /
Da-te-6f Burial: Time: am/pm
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
Monument Being Placed: 'i"? (No Fee for Staking of Monument)
• 7on%orrouY (`-Aor),ih5 . ( Fkkce C t- 4', )
November 4, 2010
Attn: Jean
Monument Co.: Casket & Monument Discount
Fax: 813-663-0512
(This fax includes a copy of Cemetery Map)
# in the circle is the Block, # in the square is the Lot
Deceased: Mary C. Shepherd
Gravesite: Block 14, Lot 538, Space
Full Space
Gravesite flagged with Green flags. No fee for staking for
placement of monument.
Nearby Burials:
Space 2 = James Shepherd
Please contact me with any questions.
Thank you,
Judith LaCosse
Staff Assistant
Official Records & Legislative Services
City of Clearwater
727-562-4093
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