Ward, James C4
Date: -?JALffiV
Funeral Home / Monument Company: Moss
Contact Name: -Pvy- t
Cemetery Call Work Sheet
Tel. #: Fax #:
Reason for call:
?-G? ?Aq 5
a
W i Fc L.U 611C (,e l llZQ.?
Deceased Name: S?P1LAE;5 L WPC12-b
Date of Birth:
/_jg/_Lq4jDate of Death
Block IS Lot J,?j_ Space
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: ( / rh /
Date of Burial: Time: am/Wh)
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) ?-VtCLO
• ?-L
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CEMETERY BURIAL INFORMATION BY BLOCK/LOT/SPACE
BLOCK : 15 LOT: 13
• DECEASED NAME: LUCILLE WARD
BLOCK: 15 LOT: 13 SPACE: 2 BURIALTYPE: FULL
BORN: 11 / 02 / 1923 DIED: 11 / 27 / 1999 INTERRED: 12 / 01 / 1999
INTERMENT NOTES:
DECEASED NAME: EDWIN H SCHENCK
BLOCK: 15 LOT: 13 SPACE: 3 BURIALTYPE: FULL
BORN: 02 / 01 / 1906 DIED: 04 / 30 / 1981 INTERRED: 05/01/1981
INTERMENT NOTES:
DECEASED NAME: SHACKELFORD
BLOCK: 15 LOT: 13 SPACE: 4 BURIALTYPE: FULL
BORN: 01 / 01 / 1901 DIED: INTERRED:
INTERMENT NOTES:
LUCILLE LARKIN SOLE SURVIVOR AS SELLER-DEED FILE
****END OF BLOCK : 15 LOT: 13 ****
•
•
Page 13 of 120
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FLORIDA DUARTM T
HEALTOF State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
A. (TYPE)
1. Name of First Middle Last Date Month Day Year
Deceased of
James C. Ward Death January 5, 2008
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Pinellas Clearwater Inst. 1765 Farrell Avenue
3. Name of Medical ddress Phone Number
David Weiland MD
Certifier 1
Medical Examiner Physician Roosevelt Blvd., Clearwater, FL 33760
771 727) 584-5182
4. Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment 13401 Indian Rocks Road
1
Moss Feaster Funeral Homes Largo, FL 33774 FH2320 (727) 562-2080
5. GhecK a. LJ The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. Betty was contacted on 1/7/08
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and thatDr. Weiland will complete and sign the medical
JAN 1 2003 certification of cause of death within 72 hours.
C. was contacted on He/she verified that
tiW Medical Examiner, will complete and sign the
medical certification of cause of death within 72 hours.
6. Funeral Director/ Si tore F No./Reg. No. Date Signed
1/7/08
-?q 5
Direct Disposer(4?
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 2320-004
E] 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.
No extension of time for filing the death certificate has been requested.
Registrar or Date Date Certificate
Subregistrar Signature Issued: 1/7/08 Due: 1/10/08 . 14 C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA
Approval Number: 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
®BURIAL STORAGE Date of Disposition January 9, 2008
OCREMATION OTHER (Specify)
Signature of Sexton
or Person-in-Charge GIL&, OA?j A F,
This permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton) and returned
within 10 days to the local County Health Department in the county where disposition occurred.
DH 328, 8/97 (Obsobtea all previous editions Distribution: White: Cemetery or Crematory
(Stock Number. 5740000-0328-2 ) Yellow: Funeral Director or Direct Disposer
Pink: Local Registrar M