Henry, Dorothy MDate: la / i`t / Q(9
Funeral Home / Monument Company:
Contact Name: An n'r c-e
cair c- 44..1(ts s CDi y.4." o • c )."•
Reason for call: Staking Request (Interment/Disinterment) (1
Cemetery Call Work Sheet
Tel. #: --746/ Fax #: 33 6,6
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
aorvitiy, {mil. I'lehry
Block 15 Lot 110 Space -
Owner of Plot:
Deceased Name:
Date of Birth: 9 / / 113. Date of Death to / l d /
Ali 00
Date of Burial: 1° / 1% /
Time: la-0 am
$30.00 Staking Fee (Funeral Home) — received on: 11 / I / 1 `t
M-o, l7 -0k 4.44 y9.S
Pen ce. +. 1I-It
Copy of permit emailed to Marro nrtrga, cc: Mark Tokar /P &R on: ll / 11 / 0/04t
******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
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: 15 Lot: 110 as of 10/14/2014
w
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED PERMIT
1 FULL HENRY, JR. RICHARD R 3/8/1945 04 / 30 / 1996 5/4/1996 2261
3 FULL HENRY OLLIE M 9/5/1926 01 / 01 / 2014 1/11/2014 1437
4 FULL HENRY ELLA M 7/12/1908 05 / 05 / 1994 5/11/1994 2157
DISINTERMENTS FROM SPACE:
No Matching Records
REINTERMENTS:
No Matching Records
Page 1 of 1
LaCosse, Judith
From: Tokar, Mark
Sent: Wednesday, October 15, 2014 8:33 AM
To: LaCosse, Judith
Subject: RE: Cemetery Staking - Full burial
Yellow flags
From: LaCosse, Judith
Sent: Tuesday, October 14, 2014 3:35 PM
To: Tokar, Mark
Cc: Sarnoff, Cherise; Wells, Alexis; Gilmore, Stephanie; Vaughan, Karen
Subject: Cemetery Staking - Full burial
Importance: High
We received a call this afternoon from Annice of Carnegie Dallas Funeral Service requesting a staking for a Full burial for:
Dorothy M. Henry in Block 15, Lot 110, Space 2 DOB: 9/25/1932 — DOD: 10/12/2014
Other burials nearby in this plot:
Space 1= Richard R Henry, Jr. - (full)
Space 3 = 011ie M Henry — (full)
Space 4 = Ella M Henry — (full)
Staking is needed by this Saturday, October le at around Noon.
Please advise me of the color of the flags being used so that we could notify the funeral home.
Thank You.
Judith LaCosse
Staff Assistant
Official Records and
Legislative Services Dept.
727-562-4093
1
October 15, 2014
Attn: Annice / Carnegie Dallas Funeral Service
Fax: 727 - 330 -7662
(This fax includes a copy of Cemetery Map)
# in the circle is the Block, # in the square is the Lot
Dorothy M. Henry
Gravesite: Block 15, Lot 110, Space 2
Gravesite flagged with Yellow flags
Nearby Burials:
Space 1 = Richard R Henry, Jr — (full)
Space 3 = 011ie M Henry — (full)
Space 4 = Ella M Henry — (full)
Staking Fee: $30.00 (Paid by funeral home)
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 at 727 - 562 -4093.
Thank you,
Judith LaCosse
Official Records & Legislative Services
City of Clearwater
WESTERN UNION II
moving money for better
oocumear CONTAINS A TRUE WATERMARK - HO. UP TO LIGHT TO VIEW
WESTERN UNION FINANCIAL SERVICES INC. ISSUER - EtigfeWoocL Coloracto MONEY
Payable at Wells Fargo Bank Grand Junction Downtown, NA., Grand linction, Colorado ORDER
PUBLIX #0480 10--30-1.4 17-087444995
A 323771 D 103014
T 1703 10
170874449954 L 000480 $ 30.00
PAY EXACTLY THIRTY DOLLARS AND NO CENTS
L._
PAY TO THE
ORDER OF / - 1 e A A te
3i3A,,e 1—e,s LH Li -Boy. Ci°4 306go
I, 11 13 MSER 11 V PUOCHAOER'O SIGNATURE
-116 r sty) r4-1,0
I:11021,00400W 4017013744499 Etoi
OFFICIAL RECORDS AND
LEGISLATIVE SERVICES '
November 17, 2014
Ms. JoAnne Lewis
1494 Box Cir
Winder, GA 30680
Dear Ms. Lewis:
CITY OF CLEARWATER
POST OFFICE Box 4748, CLEARWATER, FLORIDA 33758 -4748
CITY HALL, 112 SOUTH OSCEOLA AVENUE, CLEARWATER, FLORIDA 33756
TELEPHONE (727) 562 -4090 FAX (727) 562 -4086
We received your Money Order #17- 087444995 in the amount of $30.00 for the
for the interment of Dorothy M. Henry.
Attached you will find receipt No. 447309.
Thank you,
dith LaCosse
Staff Assistant
EMPIA ALMENT AND AFFI MMJVI ACTION EMPLOYER: