Dye, ReginaDate: 11 / 17 / d-015-
Cemetery Call Work Sheet
Funeral Home / Monument Company: � re W e.A. d- S"IA s 1f
Contact Name: . 5 L.� Tel. #:-47- 31 `f -`t`i/ l Fax #:
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:
" /Ig _oto f2�y
(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 LZ
Owner of Plot: V et It y hJ1
Deceased Name: _by�
Block No Lot 14 Space )- CC)
Date of Birth: / i 9 )-1 Date of Death /1 / ()-
Date of Burial: i I / (9 / a, I s Time: 1- D'
$30.00 Staking Fee (Funeral Home) — received on: 1a /
Copy of permit emailed to Mark Tokar, cc: Cherise Sarnoff /P &R on:
w•i 2� 6L)►� �P .vtcz Gam.
#116 Sl3
la- / Ig- / 9_0I$
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 11/24/14
Status of Block: 16 Lot: 43 as of 11/17/2015
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED PERMIT
1 FULL DYE VAN 12/3/1900 02 / 01 / 1982 2/3/1982 1458
3 FULL LE NEAUX BYI 11/25/1932 02 / 02 / 1984 2/23/1984 1550
4 FULL BLACKHALL JOHN 12/13/1932 12 / 14 / 1983 12/28/1983 1539
DISINTERMENTS FROM SPACE:
D FULL DYE
REINTERMENTS:
No Matching Records
VAN
12 / 03 / 1900 02 / 01 / 1982 05 / 03 / 1982 02 / 14 / 1992 1458
Page 1 of 1
LaCosse, Judith
From:
Sent:
To:
Cc:
Subject:
Yellow flags.
Tokar, Mark
Wednesday, November 18, 201
LaCosse, Judith
Wells, Alexis; Sarnoff, Cherise;
RE: Cemetery Staking Request
From: LaCosse, Judith
Sent: Tuesday, November 17, 2015 3:46 PM
To: Tokar, Mark
Cc: Wells, Alexis; Sarnoff, Cherise; Vaughan, Karen
Subject: Cemetery Staking Request - Urn Burial
Importance: High
5 8:38 AM
Vaughan, Karen
- Urn Burial
We received a call this afternoon from Leslie from Brewer & Sons F.H. requesting a staking for an Urn burial for:
Regina Dye in Block 16, Lot 43, Space 2 (C)
DOB — 7/26/1921- DOD 11/2/2015
Surrounding burials in this plot:
Space 1= Van Dye — full burial
Space 3 = Byi Le Neaux — full burial
Space 4 = John Blackhall — full burial
Staking is needed by this Thursday, November 19th for an (urn) burial at around 1:00 p.m.
Please advise as soon as you can the color of the flags being used so that we could notify the funeral home.
Thanks for your help.
Judith LaCosse
Staff Asst
City of Clearwater
()RLS Dept.
727 - 5624093
1
November 18, 2015
Attn: Leslie
Funeral Home: Brewer & Sons F.H.
Email: leslie @brewerfuneral.com
(Attached is a copy of the cemetery map)
# in the circle is the Block, # in the square is the Lot
Deceased: Regina Dye
Gravesite: Block 16, Lot 43, Space 2 (C)
Urn
Gravesite flagged with Yellow flags
Date of burial: Thursday, November 19th at 1:00 p.m.
Nearby Burials:
Space 1 = Van Dye - (full burial)
Space 3 = Byi Le Neaux - (full burial)
Space 4 = John Blackhall - (full burial)
Note: Staking Fee amount due: $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
FAMILY OWNED SERVICE COMPANY
PO BOX 566
BROOKSVILLE, FL 34605 12/15/2015
0
CENTENNIAL BANK
81- 275 -829
116813
PAY TO THE
ORDER OF City of Clearwater $ *"30.00 °
Thirty and 00/ 100****************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** DOLLARS i
City of Clearwater
Official Records Dept
2nd Floor
Clearwater, Fl 33756
MEMO
8
II' L 168 L31I' ':08 290 27571: 0 3 20000 34 2II'
AUTHORIZED SIGNATURE
FAMILY OWNED SERVICE COMPANY
City of Clearwater 12/15/2015
Date Type Reference Original Amt. Balance Due Discount Payment
12/15/2015 Bill Regina Dye 30.00 30.00 30.00
Check Amount 30.00
116813
Main Account
30.00
BURIAL PERMIT
CLEARWATER CARETAKER
CLEARWATER, FL
Permission is hereby granted for burial of:
Name of Deceased: REGINA DYE
Owner of Property: VAN DYE & REGINA DYE
Block : 16 Lot: 43
PERMIT # 1452
December 18, 2015
Burial Type: URN
Space: 2 Date of Birth: July 26, 1921
Date of Death: November 2, 2015 Date of Burial: November 19, 2015
Funeral Home Director: LESLIEBREWER & SONS F.H.
Time: 13 :00
Staking Fee: 30.00 Date Paid: December 18, 2015
Clearwater Cemetery
AR Ad,...„.e._
By