Shea, Joseph RobertDate: (e / / ?'>
Cemetery Call Work Sheet
Funeral Home/ Monument Company: (/ 7\
L.
Contact Name: QJ ory Oi Tel. #: S7Q
> ? Cy J
c.A.o-e.
Email:�G�.Xc:,VYeed
Reason for call:
**
Staking Request — Interment
$30.00 staking fee (Weekdays) - $50.00 staking fee (Saturday, Sunday & Legal Holiday)
Full Burial Urn Burial
(One full burial and one urn, or two urns per space)
Owner of Plot:
Deceased Name:
Block Lot
Date of Birth: /
Date of Burial:
• **
Space
/ Date of Death / /
/ Time: am/pm
V Monument (Marker) being placed - (No fee for staking of monument)
For: :Gig- �bS� ("`fid (or‘cc C">4.«. -e Ka/lice/L.)
Block 7 Lot GS—Space 3 fli, ct Date: / / Time:
Affidavit (Burial Rights) Verifying Burial space
Other reason:
***********************************************************************************************
6621
Send email to P&R to stake the space
Notify funeral home/monument company with color of the flags used to mark the space
Staking fee received on: / / From:
Copy of permit emailed to:
Nathan Brigman, cc: Matt Anderson, Tim Chaplinsky, Erick Peterson in 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
ORLS/Cemetery/FormsPermitsTemplates/Cemetery Call Work Sheet -20
Revised 4/21/2021
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Notary Public. Sltle of F1ot1da
RUTH J. WEILAND
!,' r. '10m. Exp. Nov. 28. 1996
.fl1m. No. CC 243330
FI!:B 16 'S9
11:37 AM
ALBANV MAIL SERVICES
+912 4326249
Paige
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