Morris, GwenDate: / P-L'/ a° )7
Funeral Home / Monument Company:
Contact Name:
Cemetery Call Work Sheet
4° s5 1 ►�
Tel. #: S �' - a°1°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:
(Send email to P &R) r
Verifying Burial space
Other reason:
Qre-e-ti
******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Interment: (One full burial and one urn, or two urns per space)
Full Burial .7 Urn Space
Owner of Plot:
\%∎L - °r rr■ s
Deceased Name:
Gtveh %'lam S
Block I)- Lot Space
Date of Birth: '- / i / I q3 I Date of Death 3- / 3 /
3/4 X30 !7
Date of Burial: 17 Time:` °+ ' am /pm
$30.00 Staking Fee (Funeral Home) — received on:
3 / 6/ aorl
L-4.4-(/ f kGe
Copy of permit emailed to Mark Tokar, cc: C,heri&e- &ariteff/P &R on:
JQA -it I461
)k 1 -10
******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
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
i
Status of Block: 12 Lot: 79 as of 02/24/2017
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED PERMIT
1 FULL MORRIS VICTOR 11/1/1923 02 / 19 / 2011 2/23/2011 2621
3 FULL JOHNSON JONAH W 1/1/1911 04 / 20 / 1970 4/20/1970 757
4 FULL JOHNSON TENNIE K 8/24/1911 12 / 10 / 1996 12/12/1996 2286
DISINTERMENTS FROM SPACE:
No Matching Records
REINTERMENTS:
No Matching Records
Page 1 of 1
LaCosse, Judith
From: Tokar, Mark
Sent: Monday, February 27, 2017 9:01 AM
To: LaCosse, Judith
Cc: Wells, Alexis; Bruce, Larry; Vaughan, Karen
Subject: RE: Cemetery Staking Request - Full Burial
Green flags.
From: LaCosse, Judith
Sent: Friday, February 24, 2017 2:30 PM
To: Tokar, Mark
Cc: Wells, Alexis; Bruce, Larry; Vaughan, Karen
Subject: Cemetery Staking Request - Full Burial
Importance: High
Today, we received a stal___ng request from Paul at Moss Feaster for a Full burial for:
Gwen Morris in this plot, Block 12, Lot 79, Space 2 DOB: 4/17/1931— DOD: 2/23/2017
Owner of plot: Victor Morris
Other burials nearby in this plot:
Space 1= Victor Morris, Husband (full burial)
Space 3 = Jonah W Johnson — (full burial)
Space 4 = Tennie K Johnson — (full burial)
Staking is needed by next Tuesday, February 28th — Time: unknown
Please advise me of the color of the flags being used so that we could notify the funeral home.
Thank You.
Judith LaCosse
Staff Asst
City of Clearwater
ORLS Dept.
727 - 562 -4093
MOSS FEASTER FUNERAL HOME
AND CREMATION SERVICES
693 SOUTH BELCHER ROAD
BANK OF AMERICA
64- 1278/611
I U
CLEAR WATER, FL 33764
(727) 562 -2070 3/1/2017 c
PAY TO THE
ORDER OF $ ;
City of Clearwater 30.00
DOLLARS
---Thirty And 0/100 - - - VOID AFTER 180 DAYS
CHECK CANNOT EXCEED $10,000.00
TWO SIGNATURES NEEDED IF OVER $5,000.00
MEMO
G.Morris Staking fee
v467300L4701I' 1:06LLL27881: 0033598L005L0
AUTHORIZED SIGNATURE
MOSS FEASTER FUNERAL HOME AND CREMATION SERVICES 1470
Comments
G.Morris Staking fee
Amount
30.00
30.00
MOSS FEASTER FUNERAL HOME AND CREMATION SERVICES 1470
L
L# Comments Amount
1 G.Morris Staking fee 30.00
Total forG.Morris Staking fee 30.00
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