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Catrett, Lomax (2) • Cemetery Call Work Sheet Date: / 18 I Funeral Home/ Monument Company: MoS s - e4.s-teA F. H-. /L r Contact Name: Tel. #: 1477- 5ba- a.o $o Fax#: - 596 - 3630 Reason for call: ✓ Staking Request (Interment/Disinterment) Affidavit (Burial Rights) Monument (Marker) being placed (No fee for staking of monument) Verifying Burial space Other reason: Interment: (One full burial and one urn, or two urns per space) V Full Burial v Urn Space Owner of Plot: Mrs• LA.fire_ft spkLe ._ Sl,ePt7 Deceased Name:Mrs . Lo w.,4 C&-f re-ff Block Id- Lot 3S- Space ,•1- Pe ►k,•-(- 4 Date of Birth: S / 17 / 19 I. Date of Death I / /7 / d-°/•4- Date of Burial: / 4 3 / a G /D- Time: 3:Q° pm f r- $30.00 Staking Fee (Funeral Home) — received on: /� /a6' / �'°I�- S+4-1c-Z.r, Copy of permit taxed to Joe Taylor/P&R — Fax No. 6551 on: ************************************************************************************************** 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 /la _ N + ,e Ha►,,e, ;p:2114. Revised 6/29/11 5- -1-O fLe. -dr_c e., Crystal Reports Viewer Page 1 of 1 72 I 11 4 4- 41 1 / 1 Main Report , VI, ! RI 100% Status of Block: 12 Lot: 35 as of 01/18/2012 INTERMENTS: SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH I 1 FULL CATRETT SHELBY 1/1/1911 08/29/1960 8, 3 FULL LANGTON JAMES W 1/1/1893 08/03/1966 8, 4 FULL LANGTON MABEL N 1/1/1895 12/27/1961 1: DISINTERMENTS FROM SPACE: No Matching Records REINTERMENTS: No Matching Records Page 1 of I 'l 1 / 1 http://msb-cry stal-ent/businessobj ects/enterprise 11/infoview/viewers/rpt/DHTMLViewer.a... 1/18/2012 LaCosse, Judith From: Tokar, Mark Sent: Thursday, January 19, 2012 9:13 AM To: LaCosse, Judith Cc: Ortega, Marco Subject: RE: Cemetery Staking Pink flags. From: LaCosse, Judith Sent: Wednesday, January 18, 2012 10:51 AM To: Ortega, Marco Cc: Tokar, Mark; Wells, Alexis Subject: Cemetery Staking Importance: High Hi Marco, We received a call this morning from Jerry at Moss Feaster requesting a staking for an Full burial for: Mrs. Lomax Catrett in Block 12, Lot 35,Space 2. She passed away yesterday. (See attached status sheet regarding burials in this block and lot) Staking is needed by next Monday,January 23rd for a (full) burial,scheduled at 10:00 a.m. Please advise as soon as you can the color of the flags being used so that we could notify the funeral home. Thanks for your help. Judith LaCosse Staff Assistant Official Records and Legislative Services Dept. 727-562-4093 1 January 19, 2012 Attn: Jerry Funeral Home: Moss Feaster F. H. - Largo Fax: 727-596-3630 (This fax includes a copy of Cemetery Map) #in the circle is the Block,#in the square is the Lot Deceased: Mrs. Lomax Catrett Gravesite: Block 12, Lot 35, Space 2 Full Space Gravesite flagged with Pink flags. Nearby Burials: Space 1 = Shelby Catrett - Full Space 3 = James Langton - Full Space 4 = Mabel Langton - Full Staking Fee: $30.00 Please make check payable to: City of Clearwater Mail to: City of Clearwater Official Records Dept. — 2nd Floor 112 S. Osceola Ave. Clearwater, FL 33756 Please contact me with any questions. Thank you, Judith LaCosse Official Records & Legislative Services City of Clearwater 727-562-4093 THE FACE OF THIS CHECK IS PRINTED BLUE-THE BACK CONTAINS A SIMULATED WATERMARK Moss Feaster Funeral Home&Cremati Amegy Bank N.A. 13401 Indian Rocks Road 85-1125 10621142 Porter,TX'' Largo, FL 33774 1130 01/24/2012 PAY Thirtyand 00/100 Dollars PAY TO THE CITY OF CLEARWATER ***********$30.00 ORDER OF 12 S OSCEOLA AVE CLEARWATERR, FL 33756 Memo: Staking FEE/Lomax Catrett ivri 1=.,1 ii• L062LL4211' I: LL3LL05861: 44440 70 7 20 e FLORIDA DEPARTMENT OF Oil State of Florida, Department of Health, Vital Statistics HEALT APPLICATION FOR BURIAL-TRANSIT PERMIT A. (TYPE) 1. Name of First Middle Last Date Month Day Year Deceased of Lomax Catrett DeathJanuary 17 , 2012 2. Place of Death City,Town or Location Name of (If neither,give street address) County Hosp.or Pinellas Largo Inst. Palm Garden of Pinellas 3. Name of Medical Address... hone Number Certifier Juan Escobales , MD 25815 1st Avenue NOrth n Medical Examiner n Physician St . Petersburg , Fl 33713 7 2 7-3 21-9 614 4. Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No.(Area Code) Establishment 13401 Indian Rocks Rd Moss Feaster Funeral Home Largo , Fl 33774 F041198 727-562-2080 5. Check a. ❑ The medical certification has been completed and signed. A completed certificate of death accompanies this Appropriate application. Box b. © Carol was contacted on 1/17/2012 He/she verified that this death was from natural causes,that there was no accident nor other external cause of death, and that Juan E s c o b a l e s , MD will complete and sign the medical certification of cause of death within 72 hours. c. was contacted on He/she verified that ,Medical Examiner,will complete and sign the medical certification of cause of death within 72 hours. 6. Funeral Director/ Signature F.E. No./Reg. No. Date Signed Direct Disposer (� V/..�— FOC 70 hoc- 1 /1 9/20/ B. BURIAL-TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No. 2012-41198-022 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 be-• equested. Registrar or Date Date Certificate Subregistrar Signat _ Issued: 1/17/2 012 Due: 1/27/2012 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 C lea r w a t e r Cemetery EIBURIAL D STORAGE Date of Disposition January 23 , 2012 DCREMATION DOTHER(Specify) Signature of Sexton or Person-in-Charge 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. Distribution: White: Cemetery or Crematory DH 326,8/97(Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer (Stock Number: 5740-000-0326-2) Pink: Local Registrar INSTRUCTIONS ON HOW TO COMPLETE THE APPLICATION FOR BURIAL-TRANSIT PERMIT FORM APPLICATION FOR PERMIT Section A. 1. Type name of deceased and date of death. 2. Indicate place of death: County;City,Town,or Location;Hospital or institution(if not in hospital or institution,give street address). 3. Indicate the name,address, and telephone number of the Medical Examiner or physician who is to provide the medical certification of cause of death. 4. Indicate name.address,telephone number,and license number of funeral home or direct disposal establishment. 5. a. Check if a completed death certificate,including the completed and signed medical certification of cause of death,accompanies the pink copy of the application for Burial-Transit Permit to the Local Registrar of the county in which the death occurred. (If the completed certificate cannot be obtained in sufficient time to be filed with the pink copy of the Application,check 5b.) b. Provide the name of the person contacted in an effort to obtain the name of the physician who is to complete and sign the medical certification portion of the certificate, and the date he/she was contacted. The person contacted must be either the physician or a responsible person who can speak for him/her. c. Check to indicate if this is a Medical Examiner case. Give the name of the person contacted who verified that the Medical Examiner will complete and sign the medical certification of cause of death and the date contact was made. 6. Requires the signature of applicant Funeral Director, FE License number,or Direct Disposer, Registration Number,and the date the Application was signed. BURIAL-TRANSIT PERMIT Section B. If it is anticipated that the certificate cannot be filed within five days from the date of death, five additional days (exclusive of weekends) may be requested and granted by checking the box provided. If no extension of time is requested,check appropriate box. The Registrar or Subregistrar who issues the Burial-Transit Permit will sign and date the Permit Application and assign the permit number. Section 382.006, Florida Statutes, requires that a Burial-Transit Permit be obtained prior to disposition or removal from the State and within five(5)days after death. It shall be mailed or delivered to the Local Registrar of the county in which death occurred within 24 hours after issuance. NOTE: It is not necessary to wait until the Funeral Director/Direct Disposer has custody of the actual body to begin the paperwork. AUTHORIZATION FOR CREMATION, DISSECTION, or BURIAL-AT-SEA Section C. Approval for cremation, dissection, or burial-at-sea must be authorized by the Medical Examiner. Space for his/her approval number and date are provided. In addition, space is provided for the name of the person obtaining telephone approval from the Medical Examiner and the date such approval was obtained. (NOTE:DO NOT HOLD UP FILING THE PINK COPY WHILE AWAITING MEDICAL EXAMINER APPROVAL.) CEMETERY OR CREMATORY Section D. Required:Signature of Sexton or person-in-charge(or by the Funeral Director/Direct Disposer when there is no Sexton.); check the appropriate box to indicate the method of disposition;fill in the date and place of disposition in space provided.