Wilcox, Everett H.Date: i / I S / c)-01't
Funeral Home / Monument Company:
Cemetery CaII Work Sheet
Moss re i. stems,, /
Contact Name: Joe. G4-h^- h-T Tel. #:11-1- " -- -'`f'° Fax #: 7a-1- El:, a - 4 0+3
Reason for call:
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 k Urn Space
c o)<
Owner of Plot:
Deceased Name:
GVe_ret 1-1• 14.1..Q c o<
Block la- Lot 66' Space
Date of Birth: 6 la-('1 f�lij
Date of Death
Date of Burial: / / a-019' Time:
/ IL /
Il;o
pm
b T3 s Na4,d0)
Spice 2 = Rw A, Lk) iQco"( --f
Spk.cc 3 = h ?;1-e ())iQc(3.yc -
$30.00 Staking Fee (Funeral Home) — received on: `t / / 1`f
�Qnw�it l`(-39
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: Wednesday, April 16, 2014 10:27 AM
To: LaCosse, Judith
Subject: RE: Cemetery Staking Request - Full burial
Pink flags
From: LaCosse, Judith
Sent: Tuesday, April 15, 2014 12:34 PM
To: Ortega, Marco
Cc: Tokar, Mark; Wells, Alexis; Vaughan, Karen; Gilmore, Stephanie
Subject: Cemetery Staking Request - Full burial
Importance: High
Staking request for full burial received from Moss Feaster /Dunedin.
The deceased name: Everett H. Wilcox.
Please Stake Space 2 of Block 12, Lot 66.
The date of burial will be for Saturday, April 19th at around 11:00 a.m.
Other burials nearby:
Space 1: Ruth A. Wilcox — full burial
Space 3: Alice Wilcox — full burial
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
April 16, 2014
Attn: Joe Gambino
Funeral Home: Moss Feaster /Dunedin
Fax: 727 - 562 -2043
(This fax includes a copy of Cemetery Map)
# in the circle is the Block, # in the square is the Lot
Deceased: Everett H. Wilcox
Gravesite: Block 12, Lot 66, Space 2
Full Space
Gravesite flagged with Pink flags.
Nearby Burials:
Space 1 = Ruth A. Wilcox — full burial
Space 3 = Alice Wilcox — full burial
Staking Fee: $30.00
Please make check payable to: City of Clearwater
Mail to:
City of Clearwater
Official Records Dept. — 2nd 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
04/17/2014
11599497
PAYMENT DETAILS
Staking Fee - Everett H. Wilcox
THE FACE OF THIS CHECK IS PRINTED BLUE - THE BACK CONTAINS A SIMULATED WATERMARK
Moss Feaster Funeral Home and Crema
1320 Main Street
Dunedin, FL 34698
PAY Thirty and 00/100 Dollars
Amegy Bank N.A.
Porter, TX
35 -1125
1130
11599497
04/17/2014
PAY TO THE
ORDER OF
IMR E 44
CITY OF CLEARWATER
112 S OSCEOLA AVE
Official Records - 2nd Floor
CLEARWATER, FL 33756
Memo: Staking Fee - E. Wilcox
* * * * * * * * ** *$30.00
11'L15 9 9 4 9 7116 I:LL3LL05861: 4 4 4 40 70 7 211'
NTERfED
APR '2 ,2
LE SLe-di i SaTCS '' `'
FLORIDA DEPART GiaiOE' ,� State of Florida, Department of Health, Bureau of Vital Statistics
HE ALT BURIAL TRANSIT PERMIT
DATE PRINTED: April 15, 2014 TRACKING NUMBER: 2014056230
1, DECEDENT INFORMATION
Name of Deceased Date of Death
EVERETT H WILCOX April 14, 2014
Place of Death - County City, Town or Location Name of facility, or street address if not a facility
CITRUS CRYSTAL RIVER CYPRESS COVE CARE CENTER
Name and Address of Funeral Home /Direct Disposal Establishment Fla. Lic. No. /Reg. No. Phone Number
MOSS - FEASTER FUNERAL HOME & CREMATION - DUNEDIN F040918 F040918 (727) 562 -2040
1320 MAIN ST
DUNEDIN, FLORIDA, 34698
Funeral Director /Direct Disposer Fla. Lic. No. /Reg. No.
SUSAN A. KELLY F042884
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- F040918 -5059
. 4.64. r Date Issued: April 15, 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
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
NTERfED
APR '2 ,2
LE SLe-di i SaTCS '' `'
CLEARWATER CARETAKER
CLEARWATER, FL
BURIAL PERMIT
PERMIT # 1439
April 24, 2014
Permission is hereby granted for burial of:
Name of Deceased: EVERETT H WILCOX Burial Type: FULL
Owner of Property: EVERETT H WILCOX & ALICE W WILCOX
Block : 12 Lot: 66 Space: 2 Date of Birth: June 26, 1918
Date of Death: April 14, 2014 Date of Burial: April 19, 2014
Funeral Home Director: JOE GAMBINO/MOSS FEASTER
Time: 11 :00 Staking Fee: 30.00 Date Paid: April 23, 2014
Clearwater Ceetery
By 744e-i-4-4,- ve4
Cemetery Call Work Sheet
Date: 9 / I? / X° h'
Funeral Home / Monument Company: -�c Co
Contact Name: K e Tel. #: 1 1_ 1 Fly- 1 SS I Fax #:
Reason for call: Staking Request (Interment/Disinterment)
Affidavit (Burial Rights)
V- Monument (Marker) being placed (No
For: £ve..tft H (3: QGox
Block to Lot G6 Space -'
Date: / / Time: (tu° d`te')
fee for staking of monument)
f12,cf V - ►� ,k�!
(Send email to P &R)
Verifying Burial space
Other reason:
��14GC 1 = 1 2 . ✓1, A . W t t L o " 6-12-e
J = At,. cc (,J ;fcnx -
FA- R 11+4
i
icQ f'.Q4a,3 I
o +; e
******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** 0 w. eid- Co
Interment: (One full burial and one urn, or two urns per space)
FuII 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