Cochran Jr, Donald DouglassCemetery Call Work Sheet
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Date:
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Funeral Home / Monument Company: ?..lo?S F ecc Sfie-v?
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Contact Name:
Tel. #: 1j- Of ?C1p Fax #:
Reason for call:
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Deceased Name: _'Duyy?,?( uC?4CL?S
Date of Birth: 101 Date of Death
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• Block Lot eq Space
Owner of Plot: ?S`zSl? Al, Interment: (One fu// burial and one urn, or two urns per space) to)
Full Burial Urn Space
aptY •
$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 forStaking of Monument)
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CEMETERY BURIAL INFORMATION BY BLOCK/LOT/SPACE
• BLOCK : 7 LOT: 58
DECEASED NAME: JESSIE A COX
BLOCK: 7 LOT: 58 SPACE: 1 BURIALTYPE: FULL
BORN: 01 / 01 / 1892 DIED: 01 / 18 / 1971 INTERRED: 01 / 20 /1971
INTERMENT NOTES:
DECEASED NAME: CLEVELAND T COX
BLOCK: 7 LOT: 58 SPACE: 2 BURIALTYPE: FULL
BORN: 01 / 01 / 1900 DIED: 01 / 01 / 1940 INTERRED: 01 / 01 / 1940
INTERMENT NOTES:
****END OF BLOCK : 7 LOT: 58 ****
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Page 56 of 184
•• w - w i,iv, •eiwU K mC. roan Yralrle, MN
605 22000 03
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MosE. Feaster Funeral Home(4676) Gelco Check Number
"02 North Fort Harrison Avenue 12276152 01 22 -7 615 L 1
Clearwater FL 33755
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gunterkm 8/217M8
I
{ PAY TO THE City of Clearwater NOT VALID AFTER SIX i6) MONTHS FROM ISSUE DATE
ORDER OF
112 South Osceola Avenue 8?yea.re=F
ORLS
Clearwater FL 33756
Ir
Thirty Five Dollars And No Cents*******************************************
PAYABLE THROUGH
t First PREMIER Bank
SIOUX FALLS, SD
OVER $5,000 NOT REDEEMABLE FOR CASH BY
$***35.00
THORIZED REPRESENTATIVE
William Hartgrove v t\ SIGNATURE OF DRAWERS AUTHORIZED REPRESENTATIVE
78-858 v
914 By ft instrument, the ataesgrod confirms that tNs instrument has been drawn in accordance with ft au0gdty issued by Geko Information Network, Inc. It any q .
slat herein be untrue, we ft a ensgwf, agree to pay the drawer upon demsrM the amount of ft 6aynxnent and at eVeraes and damages arising from such misstatement.
1150 1 2 276 IS 2 Lill 1:09 1408 58 511: 2 5000006 5 5Ii'
William Hartgrove gunterkm
S*NER USER ID
01 22761521.
City of Clearwater
112 South Osceola Avenue
ORLS
Clearwater FL 33756
DESCRIPTION
DATE LOCATION NUMBER GLCODES CONTRACT NUMBER NAME/DESCRIPTION AMOUNT
8/22/200 4676 8405-0 467601000561 Cochran Staking Fee $********35.00