Miller, Diana.
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Cemetery Call Work Sheet
Date: 8 / a- / a° 10
Funeral Home/ Monument Company:
Contact Name: A ??.
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Tel. #: -
Fax #: g?-7 - S F5 - 9 `f OR
Reason for call: MS
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Deceased Name: A??`? Mo ?siK"?en??Q
Date of Birth: Date of Death
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Owner of Plot:
**************************************************************************************************
Interment: (One full burial and one urn, or two urns per space)
Full Burial Urn Space
$30.00 Staking Fee - received on:
Date of 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: (No Fee for Staking of Monument)
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Authorization For Disbursement
Date:9/29/2010
Time:2:38 PM
Vendor/Payee name: Diana Miller
2nd line vendor/payee name:
Remit to: Street / PO Box 2841 E. Redwood Lane
Remit to- City, State, Zip Code Phoenix, AZ 85048
Purchase orders are required for payments in excess of $2,500.
Purchase Orders are required if prior year payments or expected payments have or will exceed $2,500.
P.O. NUMBER (if required) RELEASE # RECEIPT ;;
Provide a description or reason for this expense:
City of Clearwater paying $10.00 for donation of cemetery plot from Ms. Miller.
If you are charging more than one account please
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1 Payment for Plot 010-09700-550400-513-000 10.00
0.00
2
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3
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5
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0.00
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4. FulllloSignature I of person authorized to sign Purchase Order Receiver Copy:
Print Name and Title of person signing-4 Rosemarie Call, City Clerk
Print this form and attach the original document(s) that validate the amount you are requesting payment for. Attach
any copies that must be sent with the check. Improperly completed forms will delay check request.
Please explain below if you are requesting the Finance Department not to mail check to the vendor.
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Keyed
Created by W.M. Tedder AFD
City Clerk Document it 9821-0002
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OFFICIAL RECORDS AND
LEGISI ATIVI; SERVICES
October 13, 2010
CITY OF CLEARWATER
POST OFFICE Box 4748, CLEARWATER, FLORIDA 33758-4748
CITY HALL, 112 .SOUTH OSCEOLA AVENUE, CLEARWATER, FLORIDA 33756
TELEPHONE (727) 562-4090 FAx (727) 562-4086
Diana Miller
2841 E. Redwood Lane
Phoenix, AZ 85048
Re: Block 8, Lot 18, Space 4 - Clearwater Municipal Cemetery
Dear Ms. Miller:
Enclosed you will find the original recorded copy of the Cemetery Deed in
which you have remised, released and quit-claimed above referenced plot unto
the City of Clearwater. Along with this deed is a check in the amount of $10.00
from the City of Clearwater for your donation of this plot.
If you have any questions, please contact me at 562-4093.
Sincerely,
udith LaCosse
Staff Assistant
Enclosure(s)
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