Fairchild, VirginiaDate: r) / a `( / l3
Cemetery CaII Work Sheet
Funeral Home / Monument Company: Vote (-4- fry .S F`� 0 / F Io r act V aC
Contact Name: %, .8 (1 r Tel. #: Fax � a-G a- Fax #:
u
Reason for call: i/ Staking Request (Interment/Disinterment) c < p/ t`ttok twit G�r�
Affidavit (Burial Rights)
Monument (Marker) being placed (No fee for staking of monument)
For:
Block Lot Space
Date: / / Time:
7)30/13
(Send email to P &R) k F1/48.1,
1
Verifying Burial space
Other reason:
******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Interment: (One full burial and one urn, or two urns per space)
Full Burial Urn Space 1
Owen.:��
Deceased Name: 'VI g-/`1- /e
Owner of Plot:
Block Lot 1 11 Space a
Date of Birth: / / 19 a 3
Date of Burial:
8/ 3 / D-al3
Date of Death 7 / d ' / a v t3,
Time: a �S am/ li
$30.00 Staking Fee (Funeral Home) — received on:
o k 7 L L t ( ( I ) a - / - 7 2
Fes)
J-� 4t i `L3 `t
/3 (le..1erC1,o
5-9,319
p�sz
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
Status of Block: 7 Lot: 111 as of 07/30/2013
r
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED PERMIT
1 FULL FAIRCHILD OWEN 5/19/1921 02 / 04 / 2002 2/7/2002 2492
3 FULL HAUS MICHAEL J 1/1/1878 01 / 07 / 1945 1/7/1945 0
4 FULL HAUS FRANCES A 1/1/1901 12 / 13 / 1968 12/13/1968 669
DISINTERMENTS FROM SPACE:
No Matching Records
REINTERMENTS:
No Matching Records
Page 1 of 1
LaCosse, Judith
From: LaCosse, Judith
Sent: Wednesday, July 31, 2013 11:35 AM
To: Ortega, Marco
Cc: Tokar, Mark; Wells, Alexis; Gilmore, Stephanie; Vaughan, Karen
Subject: RE: Staking Request - Block 7, Lot 111, Space 2
Thank You. We will notify the funeral home.
From: Ortega, Marco
Sent: Wednesday, July 31, 2013 11:33 AM
To: LaCosse, Judith
Cc: Ortega, Marco; Tokar, Mark; Wells, Alexis; Gilmore, Stephanie; Vaughan, Karen
Subject: Re: Staking Request - Block 7, Lot 111, Space 2
Pink flags, all set.
On Jul 30, 2013, at 8:42 AM, "LaCosse, Judith" < Judith .LaCosse @myClearwater.com> wrote:
We received a call yesterday late afternoon from Adam of Veterans Funeral Home requesting a staking
fora full burial for:
Virginia Fairchild — passed away July 26th
Block 7, Lot 111, Space 2
Other burials nearby in BIk 7, Lot 111:
Space 1= Owen Fairchild, husband of Virginia Fairchild — (Full burial)
Space 3 = Michael 1 Haus — (Full burial)
Space 4 = Frances A Haus — (Full burial)
Staking is needed for burial for this Saturday. August 3'd between 12:45 and 1:00 p.m.
Please advise as soon as you can the color of 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
VEIEHANS FUNEHAL CARE, INC.
City of Clearwater
Item to be Paid - Description
Check Number:
Check Date:
59219
Jul 30, 2013
Check Amount: $30.00
Discount Taken
V. Fairchild
0 Gl�
Amount Paid
30.00
' • _ •NTAINST•NER ADNE ION PR• • E- I
Memo:
PAY
TO THE
ORDER
OF
DOCUMENT INCLUDES VISIBLE FIBERS CHEMICAL REACTIVE PROPERTIES AND FEATURES A FOIL HOLOGRAM
VETERANS FUNERAL CARE, INC.
15381 ROOSEVELT BLVD.
CLEARWATER, FL 33760
(727) 524 -9202 OR 1- 800 - 467 -7850
Thirty and 00 /100 Dollars
City of Clearwater
112 South Osceola Ave
Attn: Judith - Official Records
Clearwater, FL 33756
TRUE WATERMARK PAPER - HOLD TO LIGHT TO VIEW
®Shield
63- 9138/2631
BB&T
1- 800 -BANK BBT BBT.com
DATE
59219 's
NUMBER
AMOUNT
Jul 30, 2013 * * * * * * * ** *$30.00
VOID AFTER 120 DAYS
M.
11'000005921911' 1:263L9L3871:LL0000L3L5L5LII'
HEAT SENSITIVE RED IMAGE DISAP ' - WITH HEAT
CLEARWATER CARETAKER
CLEARWATER, FL
BURIAL PERMIT
PERMIT # 1434
August 05, 2013
Permission is hereby granted for burial of:
Name of Deceased: VIRGINIA FAIRCHILD Burial Type: FULL
Owner of Property: OWEN FAIRCHILD & VIRGINIA FAIRCHILD
Block : 7 Lot: 111 Space: 2 Date of Birth: February 8, 1923
Date of Death: July 26, 2013 Date of Burial: August 3, 2013
Funeral Home Director: ADAM/VETERANS FUNERAL HOME & HARRY/FLORIDA VAULT
Time: 13 :00
Staking Fee: 30.00 Date Paid: August 1, 2013
Clearwater Cemetery
8
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