Kelleher, Dell Valentine Cemetery Call Work Sheet
Date: II / / a'
Funeral Home / Monument Company:
Contact Name: ben V likcler
Tel. #: Fax #: sea vale►t"fisyte G 6f,,„.,,;,Q.c,rvN
Reason for call: Staking Request (Interment/Disinterment)
Affidavit (Burial Rights)
Monument (Marker) being placed (No fee for staking of monument)
✓ Verifying Burial space Cs) for lots ow"cd 47 "``"'44' a�G"-tS
LoYs t ovx H. Nadu €.. V412t, f;�.e
Other reason: 4,, rewt-G.,aJp tr�tifs cfNs� h4►,,�,
0 d �C c i.e,2
O 0 .k '7, Lof 8a , sP�� /-`f V .eO;•.
**************************************************************************************************
Interment: (One full burial and one urn, or two urns per space) 2Q 0 Jk ) Lof ,
SpA,44../y. 1-!o , ow -e
Full Burial Urn Space E t elti„Qe, 6Seorc5-e-
Owner of Plot: �0 �k q 1 Lot 5c,
Spt.c -s. [— `t � ew R
Deceased Name: La- E` cLd
Block Lot Space A
�1QSo ,'prov( �e�Q ,4 dd.,"
Date of Birth: / / Date of Death
Date of Burial: / / Time: am/pm
$30.00 Staking Fee (Funeral Home) — received on: / /
Copy of permit faxed 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
Revised 6/29/1 1
LaCosse, Judith
From: LaCosse, Judith
Sent: Monday, April 30, 2012 2:49 PM
To: 'dell kelleher
Subject: RE: Burial Locations
Attachments: Affidavit-Valentine Kelleher.doc
Importance: High
Dell,
Here's another revised copy of the Affidavit. I added your brother's name on the document.
If you're in agreement with this affidavit, please sign it and have it notarized. After it has been notarized, please fax me
a copy to 727-562-4086 to keep in our files. You keep the original copy for your records.
Below is a funeral home contact name and phone number for you to arrange the burial.
Moss Feaster Funeral Home located at 802 N. Ft. Harrison Ave. in Clearwater. Contact Cliff Stewart at 727-446-2375.
As I mentioned earlier a funeral director must supervise the interment. The funeral home will then call us to have the
area staked for the burial.
If you have any other questions, please give me a call.
And, I'm sorry for your loss... May he rest in peace.
Best regards,
Judith LaCosse
Staff Assistant
Official Records and
Legislative Services Dept.
727-562-4093
From: dell kelleher fmailto:seavalentineCa�hotmail.comj
Sent: Monday, April 30, 2012 1:45 PM
To: LaCosse, Judith
Subject: RE: Burial Locations
Importance: High
hi Judy i recieved the affidavit and the name of the deceased is Kevin Patrick Kelleher...can i write that in snd have it
notorized or are you going to type it in and i will then have it noterizedmn then do i fax it back to you or what next??
Thanks for all your help
—Dell—
Subject: FW: Burial Locations
Date: Mon, 30 Apr 2012 11:46:22 -0400
From: Judith.LaCosse(amyClearwater.com
To: seavalentine(&hotmail.com
1
Hello Again,
Here's a draft copy of the Affidavit. Please review this document and let me know if you're in agreement. I still need to
add your brother's name on it.
If you have any questions, please give me a call.
Thanks.
Judith LaCosse
StaffAssistant
Official Records and
Legislative Services Dept.
727-562-4093
From: LaCosse, Judith
Sent: Monday, April 30, 2012 9:49 AM
To: 'seavalentine @hotmail.com'
Subject: Burial Locations
Hi Dell,
Attached you will find reports showing burial locations for plots owned by your grandparents and great-grandparents per
our telephone conversation on Friday, April 27th
I will be sending you the draft copy of an affidavit regarding burial rights soon, but I need your brother's name.
Please advise the name of your brother.
Thanks,
Judith LaCosse
Staff Assistant
Official Records and
Legislative Services Dept.
727-562-4093
2
Cemetery Tracking System Page 1 of 1
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Cemetery Cemetery Tracking System -View Lot Profile
; File
1 Transaction Block:7 Lot: 82
Profile Summary I
View Lot Profile
Click'View Assigned'to view interment details.If more than one individual is interred in a space,a
second grid will appear below,displaying all of the individuals assigned to the space.Click'View'on the
;u Reports second grid to view the interment details of that individual.
Print Beal Permit
(WEST SIDE OF MYRTLE AVENUE I
Search Names and Space Owner Last Owner First Owner Middle Max Interred Total Assigned Interred
Notes
1 VALENTINE WILSON H 0 0 0 View Assigned
Searc.:h...01_d 2 VALENTINE WILSON H 1 1 1 View Assigned
Locations 3 VALENTINE WILSON H 1 1 1 View Assigned
Print/Vi.e.w...L.ot 4 VALENTINE WILSON H 1 1 1 View Assigned
Status
1
Monthly Memo
Disinterments 4
Dec.eased._.b
Location
I Alphabetical List of
Dece.a..sed...File. 1
List of Owners File
1 Reinterments
S Permits List by
Deceased.
Permits List by
Location
PRBurial
I
s Maintenance
I
G.nr?.tml.._U.a.ta. ,
IValid Locations
Sec.urltY.
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http://clearwater/Apps20/cemetery/viewlotprofile.aspx?b=7&1=82 4/27/2012
Status of Block: 7 Lot: 82 as of 04/27/2012
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED PERMIT
2 FULL VALENTINE WILSON H 1/1/1902 01/02/ 1969 1/4/1969 676
3 FULL VALENTINE MODELLE E 7/26/1914 05/10/1985 5/13/1985 1620
4 INFANT VALENTINE WILSON H 9/10/1943 09/19/1943 9/19/1943 0
DISINTERMENTS FROM SPACE:
No Matching Records
REINTERMENTS:
No Matching Records
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Ci Cemetery
r,:
,,,3 File Cemetery Tracking System - View Lot Profile
'Transaction I Block:6 Lot: 29
Profile Summary
View Lo_t Profile
Click'View Assigned'to view interment details.If more than one individual is interred in a space,a
second grid will appear below,displaying all of the individuals assigned to the space.Click'View'on the
c4i Reports second grid to view the interment details of that individual.
Print Burial Permit
'EAST SIDE OF MYRTLE AVENUE
Search Names and ,
Space Owner Last Owner First Owner Middle Max Interred Total Assigned Interred
Notes
1 EICHELBERGER GEORGE 0 0 0 View Assigned
• .5.i38E.c.tuald 2 EICHELBERGER GEORGE 1 1 1 View Assigned
• Locations
3 EICHELBERGER GEORGE 1 1 1 View Assigned
Print/View Let 1 4 EICHELBERGER GEORGE 1 1 1 View Assigned
Status 5 EICHELBERGER GEORGE 1 1 1 View Assigned
Monthly Memo 6
EICHELBERGER GEORGE 1
EICHELBERGER GEORGE
0 1 1
0
0 View Assigned
7
View Assigned
Disinterments 8 EICHELBERGER GEORGE 1 1 1 View„Assigned
9
Oe.oed.4 EICHELBERGER GEORGE 1 1 1 View Assigned
a ..1
Location ; 10 EICHELBERGER GEORGE 1 1 1 View Assigned
Alphabetical List of
Deceased...File 12
List of Owners File 1
Reinterments
I
Permits List by
i .12.e.c.c.a.5.ed
Permits List by
Location
I 1
I PRBurial
, I
, I
Maintenance
Control:Data 1
1
I Valid Locations
1 1
secui:ity.
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Updated on Tuesday,January 06,2009
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http://clearwater/Apps20/cemetery/viewlotprofile.aspx?b=6&1=29 4/27/2012
Status of Block: 6 Lot: 29 as of 04/27/2012
II
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED PERMIT
2 FULL COACHMAN CARL H 12/6/1849 08/18/ 1955 8/18/1955 1171
3 FULL COACHMAN HORACE H 1/22/1919 01 /15/1991 1/18/1991 1948
4 FULL CRILE OLIVER M 1/1/1901 07/29/1965 7/31/1965 448
5 FULL CRILE BLANCHE E 1/18/1882 03/28/ 1963 3/29/1963 265
6 FULL EICHELBERGER WILLIAM H 1/1/1853 01 /01 / 1938 1/1/1938 0
8 FULL EICHELBERGER VIOLET N 1/1/1889 01 /01 /1919 1/1/1919 0
9 FULL NELSON BERNICE C 1/1/1910 09/12/1955 9/12/1955 1176
10 FULL CRILE HARRY A 1/1/1901 08/ 13/ 1963 8/24/1963 302
11 FULL GLESSNER JOHN 1/1/1872 09/23/ 1958 9/23/1958 1347
12 FULL SMITH EDWARD H 1/1/1879 07/30/ 1958 7/30/1958 1340
13 FULL SMITH CARRIE C 1/1/1877 01 /01 / 1956 1/1/1956 0
14 FULL THORPE LISLE M 1/1/1884 01 /01 /1980 1/1/1980 0
15 FULL THORPE THYRA R 1/1/1889 06/14/ 1956 6/14/1956 1214
DISINTERMENTS FROM SPACE:
No Matching Records
REINTERMENTS:
No Matching Records
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A r File
Transaction Block:9 Lot:55
Profile Summary
View Lot PE:ofile
Click'View Assigned'to view interment details.If more than one individual is interred in a space,a
second grid will appear below,displaying all of the individuals assigned to the space.Click'View'on the
Reports second grid to view the interment details of that individual.
I Print Burial Permit
IWEST SIDE OF MYRTLE AVENUE
Search Names and
Note. Space Owner Last Owner First Owner Middle Max Interred Total Assigned Interred
1 EICHELBERGER PAULINE 1 1 1 View Assigned
] Search__Old 2 EICHELBERGER PAULINE 1 1 1 View Assigned
Locations 3 EICHELBERGER PAULINE 0 0 0 View Assigned
Ednt./View._Let 4 EICHELBERGER PAULINE 0 0 0 View Assigned
i slaws
i
Monthly Memo 1
Disinterments
ID.eced.s.ed....t?:X
Location
Alphabetical List of
D ece.a.se.d.._Fill.e.
List of Owners File
IReinterrnents 1
Permits List by
Deceased
Permits List by
Location
PRBurial
I I
1 S Maintenance
con tcolDate
Valid Locations
.....S.e.c..ei.rity.
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Updated on Tuesday,January 06,2009
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http://clearwater/Apps20/cemetery/viewlotprofile.aspx?b=9&1=55 4/27/2012
Status of Block: 9 Lot: 55 as of 04/27/2012
-
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED PERMIT
1 FULL EICHELBERGER GEORGE A 7/25/1884 03/09/1948 3/9/1948 0
2 FULL EICHELBERGER PAULINE 9/4/1893 02/06/1986 2/8/1986 1647
DISINTERMENTS S FROM SPACE:
No Matching Records
REINTERMENTS:
No Matching Records
Page 1 of 1
,FROM , (TUE)MAY 1 2012 9:43/ST. 9:43/No.7500000552 P 2
AFFIDAVIT
STATE OF FLORIDA)
COUNTY OF PINELLAS)
1, Dell Valentine Kelleher,the undersigned,do hereby attest that I am the descendant of Wilson
H. &Modelle E. Valentine, my grandparents,who are buried in Spaces 2&3 of Block 7, Lot 82
and the owners of Block 7. Lot 82, Spaces 1 through 4 in the Clearwater Municipal Cemetery.
Please take this affidavit as your authority to assign interment rights in the vacant Space 1 in
Block 7, Lot 82 to myself. I authorize the interment of my brother.Kevin Patrick Kelleher,deceased,
in Space 1.
I understand that the maximum capacity of a space is two burials provided at least one person is
cremated.
I agree to release, indemnify and hold the City of Clearwater harmless from liability in the event of
any claim arising from the use of the above described property as stated above.
-IGNATURE ADDRESS/PHONE
. 1 „' /./ is-fa a
Dell Valentine Kelleher
��Q�y� —f r
3 37S-T
SWORN TO and subscribed before me this i2/ day of V)A•l , 2012 by Dell
Valentine Kelleher who produced identification in the form of FL-Di_£4{t l'1.P tp 0 SIZA and
who did/did not take an oath.
SANDRA RARcIA .04 (1,214
Notary Public Mew
`STATE
NOTARY
FLORIDA 4/27120/11
'.'"2.6-4_1:7';:-
-�- • Cana end My comm isle expires:
• Exilree 4/2712014
„FROM (TUE)MAY 1 2012 9:43/ST. 9:43/No.7500000552 P 1
ChE STEP PRINT&COPf CENTERS
186'7 Gulf to Bay alvd•Claarwatar, FL 33765
(7Z ) '442.6'566 • Fax(727) 442-6425
•
•
To : 3-v y LA Coss • cro rrt
' Fax # 727r . Phon.e #
P hone # _ 7? 7_ Cn Fax. #
safe 51.07 • Pages : •
•
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