Woods, LucilleCemetery Call Work Sheet
Date: 3 / -7 / 49-°1`f
Funeral Horne / Monument Company: �° ss S t�
Contact Name: Ke-vct Frk-it ICI-"— Tel. #: -?-4%x #: S6 a- .90 13
Reason for call: 7-Staking Request (Interment/Disinterment)
Affidavit (Burial Rights)
Monument (Marker) being placed (No fee for staking of monument)
For:
Block Lot Space
Date: / / Time:
(Send email to P&R)
Verifying Burial space
Other reason:
******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Interment: (One full burial and one urn, or two urns per space)
Full Burial ✓ Urn Space
Owner of Plot: tia -r (A)004S P R Li QLE N(ae Wo oety
Deceased Name: Lu c- tk L)000
Block V Lot as Space `3
Date of Birth: 11 / I? / I 9 aL Date of Death
Date of Burial: 3 / 11 / a-• Time:
3/ 40. / (i.
$30.00 Staking Fee (Funeral Home) — received on: 3 / / `f' / a °1 `f"
A li;e WoaaP„
PRAM' 1+3g
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: 8 Lot: 25 as of 03/07/2014
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED
1 FULL WOODS LILLIE M 12/31/1900 09 / 11 / 1993 9/14/1993
2 FULL SEVERANCE OLA 1/1/1882 05 / 15 / 1972 5/15/1972
DISINTERMENTS FROM SPACE:
No Matching Records
REINTERMENTS:
No Matching Records
Page 1 of 1
PERMIT
2117
914
LaCosse, Judith
From: Ortega, Marco
Sent: Monday, March 10, 2014 10:30 AM
To: LaCosse, Judith
Cc: Ortega, Marco; Tokar, Mark; Wells, Alexis; Gilmore, Stephanie; Vaughan, Karen
Subject: Re: Cemetery Staking Request - Full burial
Marked in pink.
On Mar 7, 2014, at 3:49 PM, "LaCosse, Judith" < Judith .LaCosse@myClearwater.com> wrote:
Staking request for full burial received from Kent Franklin of Moss Feaster Funeral Home.
The deceased name is Lucille Woods. Please Stake Space 3 of Block 8, Lot 25.
The date of burial will be for March 11`h at 10:00 a.m.
Other burials nearby:
Space 1: Lillie M Woods — full burial (mother of Lucille Woods)
Space 2: Ola Severance — full burial (grandmother of Lucille Woods)
Please advise me of the color of flags being used so that I could notify the funeral home.
Thank you.
Judith LaCosse
Staff Assistant
Official Records and
Legislative Services Dept.
727-562-4093
March 10, 2014
Attn: Kent Franklin
Funeral Home: Moss Feaster Funeral Home
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: Lucille Woods
Gravesite: Block 8, Lot 25, Space 3
Full Space
Gravesite flagged with Pink flags.
Nearby Burials:
Space 1 = Lillie M Woods — (full) mother of Lucille Woods
Space 2 = Ola Severance — (full) grandmother of Lucille Woods
Staking Fee: $30.00
Please make check payable to: City of Clearwater
Mail to:
City of Clearwater
Official Records Dept. — 2 "d 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
Vendor CITY OF CLEARWATER
Vendor No. 3141616
Amount *******$30.00
03/11/2014
11553228
PAYMENT DETAILS
Woods - 467301002034
THEFACEOFTHIS= . ECK I E!Fit TED . :1'1) BA CO IN A, SIMULATE E- r 'AK`` R '
Moss Feaster Funeral Home and Crema
693 South Belcher Road
Clearwater, FL 33764
PAY Thirty and 00 /100 Dollars
Amegy Bank N.A.
Porter, TX
35 -1125
1130
11553228
03/11/2014
PAY TO THE
ORDER OF
• ThPIE
CITY OF CLEARWATER
112 S OSCEOLA AVE
CLEARWATER, FL 33756
Memo: Woods - 467301002034
* * * * * * * * *x *30.00
II'LL55322B" a:Li, 3LL0586: 44,407072»
.-
FLDRlD3DiI'ARr IE�rgF' ; State of Florida, Department of Health, Bureau of Vital Statistics
HEALT BURIAL TRANSIT PERMIT
DATE PRINTED: March 10, 2014 TRACKING NUMBER: 2014035131
1. DECEDENT INFORMATION
Name of Deceased Date of Death
LUCILLE WOODS March 6, 2014
Place of Death - County City, Town or Location Name of facility, or street address if not a facility
PINELLAS CLEARWATER 1528 TILLEY AVEUE
Name and Address of Funeral Home /Direct Disposal Establishment Fla. Lic. No. /Reg. No. Phone Number
MOSS - FEASTER FUNERAL HOME & CREMATION -S BELCHER F040919 F040919 (727) 562 -2070
693 SOUTH BELCHER RD
CLEARWATER, FLORIDA, 33764
Funeral Director /Direct Disposer Fla. Lic. No. /Reg. No.
KENT J. FRANKLIN F075987
2. BURIAL - TRANSIT PERMIT
The Florida Department of Health, Bureau of Vital Statistics
hereby grants permission to dispose of this body in accordance with Chapter 382, Florida Statutes.
Permit Number: 2014- F040919 -5048
4.G /;4./i Date Issued: March 6, 2014
Meade Grigg, State Registrar
3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL -AT -SEA, or HOSPITAL DISPOSITION
Authorization given by Medical Examiner District Approval Number:
4. CEMETERY OR CREMATORY
Place of Disposition: CLEARWATER CEMETERY �/ 20 Method of Disposition: BURIAL Date of Disposition:
EDRS maintains all statutorily required information regarding the death record and related
burial transit permit, therefore, returning the permit to the county health department is no
longer required.
If the Place of Final Disposition wishes to retain the copy of the permit for their file they may do so.
DH 326E, 10/12
64V- 1.011, Florida Administrative Code
Date: ± / I /
Funeral Home / Monument Company:
Contact Name: /Cev i A
Cemetery Call Work Sheet
C y c w Mo vuu w. e-tA- - C o,
Tel #: 1d -1 -'1 ?(. -1557 Fax #:-1a - ?- 7SS -0 $$e•
Reason for call: Staking Request (Interment/Disinterment)
Affidavit (Burial Rights)
✓ Monument (Marker) being placed (No fee for staking of monument)
For: Lkci0i2e Loo s
Block g Lot a-5 Space 3
Date: / / o1-01Y- Time:
(Send email to P &R) V 014-1-e. �> Q� ,, ee-C.
Verifying Burial space
Other reason:
******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Interment: (One full burial and one urn, or two urns per space)
Full Burial
Owner of Plot:
Deceased Name:
Urn Space
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
LaCosse, Judith
From: Tokar, Mark
Sent: Monday, April 21, 2014 11:15 AM
To: LaCosse, Judith
Subject: RE: Staking request - Placement of memorial marker
White flags.
From: LaCosse, Judith
Sent: Friday, April 18, 2014 1:33 PM
To: Tokar, Mark
Cc: Wells, Alexis; Vaughan, Karen; Gilmore, Stephanie
Subject: Staking request - Placement of memorial marker
Importance: High
We just received a call for a staking request from Kevin of Cycadia Monument Co. for placement of a memorial marker
for the following:
Lucille Woods — Block 8, Lot 25, Space 3 (buried in this space)
Burials nearby:
Space 1= Lillie M. Woods — full
Space 2 = Ola Severance —full
If possible Kevin would like to have the above space flagged by next Thursday, April 24th.
Please let me know the color of the flags so that we could notify Cycadia Monument Co.
Thank You.
Judith LaCosse
Staff Assistant
Official Records and
Legislative Services Dept.
727-562-4093
1
February 27, 2014
Attn: Kevin Cantrell / Cycadia Monument Co.
Fax: 727 - 785 -0856
(This fax includes a copy of Cemetery Map)
# in the circle is the Block, # in the square is the Lot
Lucille Woods
Gravesite: Block 8, Lot 25, Space 3
Gravesite flagged with White flags
Nearby Burials:
Space 1 = Lillie M. Woods - full
Space 2 = Ola Severance - full
Please contact me with any questions at 727 - 562 -4093.
Thank you,
Judith LaCosse
Official Records & Legislative Services
City of Clearwater