Paciorek, Henry F Cemetery Call Work Sheet
Date: / 1-1 / 0-4'1 a`
Funeral Home/ Monument Company: SCI - Ss t'ek.
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-
Contact Name: Pi ek Tel. #: 6 a "4°1v Fax#: 56a-a-013
Reason for call: Staking Request (Interment/Disinterment)
Affidavit (Burial Rights)
Monument (Marker) being placed (No fee for staking of monument)
For: )+evxry F Peclorek
Block 7 Lot ) $ Space
Date: )a- / 3I / 30 ) a Time: �or^-mot
W"-VV- I", cr t �4c ore k
(Send email to P&R) V
Verifying Burial space
Other reason:
Interment: (One full burial and one urn, or two urns per space)
Full Burial Urn Space
Owner of Plot:
Deceased Name:
Block Lot Space
Date of Birth: / / Date of Death / /
Date of Burial: / / Time: am/pm
$30.00 Staking Fee (Funeral Home) - received on: / /
Copy of permit emailed to Marco Ortega, cc: Mark Tokar/P&R 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 10/31/12
1
Status of Block: 7 Lot: 18 as of 12/17/2012
,
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED PERMIT
1 FULL GURLEY RALPH B 9/6/1912 07/22/1939 7/22/1939 0
2 FULL PACIOREK HENRY F 7/15/1921 07/10/1998 7/14/1998 2374
3 FULL SKEEN EDWARD J 9/12/1899 03/08/1958 3/11/1958 1322
4 FULL SKEEN BESSIE B 2/13/1900 05/17/1979 5/21/1979 1316
DISINTERMENTS FROM SPACE:
No Matching Records
REINTERMENTS:
No Matching Records
Page 1 of 1
LaCosse, Judith
From: LaCosse, Judith
Sent: Wednesday, December 19, 2012 8:26 AM
To: Ortega, Marco
Cc: Tokar, Mark; Wells, Alexis; Gilmore, Stephanie; Vaughan, Karen
Subject: RE: Cemetery Staking for Placement of a marker
Thank You!! I will notify the funeral home.
From: Ortega, Marco
Sent: Wednesday, December 19, 2012 6:32 AM
To: LaCosse, Judith
Cc: Tokar, Mark; Wells, Alexis; Gilmore, Stephanie; Vaughan, Karen
Subject: RE: Cemetery Staking for Placement of a marker
Marked in green flags.
From: LaCosse, Judith
Sent: Monday, December 17, 2012 3:13 PM
To: Ortega, Marco
Cc: Tokar, Mark; Wells, Alexis; Gilmore, Stephanie; Vaughan, Karen
Subject: Cemetery Staking for Placement of a marker
Importance: High
We received a call this afternoon from Rick of SCI—Moss Feaster regarding placement of a marker.
Would it be possible to have Block 7,Lot 18,Space 2 staked for this Friday, December 21st in the morning.
Name of deceased in space 2—Henry F. Paciorek Owner—Myrtle Paciorek
Other Full Burials nearby in Block 7, Lot 18:
Space 1—Ralph B Gurley—Full burial
Space 3—Edward J Skeen—Full burial
Space 4—Bessie B Skeen—Full burial
Please let me know the color of the flags you will be using so that I could notify Moss Feaster.
Thank You.
Judith LaCosse
Staff Assistant
Official Records and
Legislative Services Dept.
727-562-4093
1
December 19, 2012
Attn: Rick
Funeral Home: SCI — Moss Feaster
Fax: 727-562-2073
(This fax includes a copy of Cemetery Map)
#in the circle is the Block,#in the square is the Lot
Deceased: Henry F. Paciorek
Gravesite: Block 7, Lot 18, Space 2
Full space
Gravesite flagged with Green flags.
Nearby Burials:
Space 1 = Ralph B Gurley— Full burial
Space 3 = Edward J Skeen— Full burial
Space 4 = Bessie B Skeen — Full burial
(No staking fee charge for marker being placed)
Please contact me with any questions.
Thank you,
Ladosse
Official Records & Legislative Services
City of Clearwater
727-562-4093