Clark, Patricia AnnCemetery Call Work Sheet
Date: ' / .a 3-
Funeral Home / Monument Company: M ° s 5 feet s -t'r
Contact Name: -0(7- (ei-m. n0 Tel. #: -137- St, -a° )O 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) 1�
Verifying Burial space
Other reason:
******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Interment: (One full burial and one urn, or two urns per space)
Full Burial Urn Space
Owner of Plot: [er7 C1 4
Deceased Name: Pat( L.`, 4 A,,,l, C. kr k
Block ` it Lot Ln5 Space 00
Date of Birth: 1 0-1- / `W Date of Death 11 / /'/7
g- , 13'8—
Date of Burial: ID-/ X / '3- °/1 Time: -:vv am
f-�� -r lot
Cakix 4- (s (9-7
$30.00 Staking Fee (Funeral Home) — received on: I / / 10/7 tcsTel
Copy of permit emailed to Mark Tokar, cc: Cherise Sarnoff /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 11/24/14
CONTRACT TO PURCHASE CEMETERY SPACE
THIS CONTRACT, made and entered into this day of
OCT0'li . , 20 t7 , between the City of Clearwater as "GRANTOR" and
Terry D. Clark , whose mailing address is 1428 S. Hillcrest Ave. ,
Clearwater, FL 33756 , of the County of Pinellas, State of Florida,
as "PURCHASER ":
WITNESSETH: That in consideration of the mutual promises and
covenants herein contained, and other valuable considerations, the Grantor
agrees to sell and the Purchaser agrees to buy the following described space:
Block 14 , LotS `laSy `IOH (Urn Spaces) L(� 3 402-, Clearwater
Cemetery, as recorded in Plat Book 60, Page 30, Public Records of Pinellas
County, Florida.
PURCHASE PRICE
RECORDING FEE
DOC STAMPS
$ 125.00 per urn = t)r1 -ti% ( -
$ 10.00 (+ $8.50 add'I page)
$ 3.50
Total balance due is $ 5 13n 5t%. In the event of default in the balance due, the entire sum may be immediately declared due
in full. Failure of the purchaser to make said payment shall entitle the Grantor to retain all proceeds theretofore paid, as liquidated
damages, and may also retain title to any part or portion of said property which has not been used for grave space, and thereupon this
contract shall become null and void.
NO SPACE SHALL BE USED AS A BURIAL SITE UNTIL THE CONTRACT HAS BEEN PAID IN FULL.
THE PURCHASER FURTHER AGREES to abide by all rules and regulations governing the use and maintenance of space(s)
in Clearwater Cemetery. This contract shall not be assigned nor shall any grave space sold hereunder be transferred without the
written consent of the City of Clearwater.
The obligations and benefits under this contract shall extend to the personal representatives and heirs of the Purchaser and
the successors of the City.
TNESS WHEREOF, said parties have set their hands and seals the day and year first above written.
PURCHASER(S)
(Witness as to Purchaser)
. A.--tt-e— t it— bli _Ai)
il e c o i- ti-- Et E.
-- 1-4(?4st,--iCe r`:-14Y1A
address (please print)
Attest:
Nicole Sprague, De•uty Cit
Approved as to form:
Paul Richard Hull, Assistant City Attorney
STATE OF FLORIDA )
COUNTY OF PINELLAS)
.1I■i(9
Before me personally appeared , the City Man er of the above named city, who acknowledged that he
executed the foregoing instrument. He is personally known to me and did not take an oath.
WITNESS my hand and official seal this 110- ay of It.JU�M\zseeI, 20 1 Pi.
( ' ness
7
as to Purc hg
13RK S H
address (please print)
er�
(1 { °i/►�al,
(v-us /eve
elegy 1,0 (del
33
CITY OF CLEARWATER, FLORIDA
By:
William B. Horne, City Manager
COUNTERSIGNED:
By: `c(e0(Itf‘Cre.15
George N. Cretekos, Mayor
(SEAL)
<vP SANDRA HARRIGER
0416MY COMMISSION # FF930375
'�4� EXPIRES: January 04, 2020
Before me personally appeared George N. Cretekos, the Mayor of the above
the foregoing instrument. He is personally known to me and did not take an oath.
WITNESS my hand and official seal this / - i day of /4/Cm hK , 20/7.
(SEAL)
CONTRACT. DOC
tas Notary Public State Florida
Patricia A K
Pa A uligows ki
My Commission GG 131393
Expires 10/2012021
Print name:
kl
Notary Public
named city, who acknowledged that he executed
Print nam
Nota •'Public
9700 -0027
Rev. 10/17
CEMETERY DEED
KEN BURKE, CLERK OF COURT
AND COMPTROLLER PINELLAS COUNTY, FL
INST# 2017351700 11/16/2017 03 :27 PM
OFF REC BK: 19844 PG: 1743 -1743
DocType:DEED RECORDING: $10.00
D DOC STAMP: $4.20
THIS INDENTURE made this 30th day of October 2017, between the City of
Clearwater, Florida, a municipal corporation as Grantor and Terry D. Clark , whose mailing
address is 1428 S. Hillcrest Ave., Clearwater, FL 33756 of the County of
Pinellas, State of Florida, as Grantee:
WITNESSETH: That the said Grantor, for and in consideration of the sum of $513.50 in hand paid by the said Grantee, the
receipt whereof is hereby acknowledged, has remised, released and quit - claimed unto the said Grantee, and their heirs forever, all the
right, title and interest, which the said Grantor has in and to the following described parcel of land, lying and being in Pinellas County,
State of Florida, to wit: Block 14, Lots 402, 403, 404 & 405 (Urn Spaces) , Clearwater Cemetery, as recorded in Plat Book 60,
Page 30, Public Records of Pinellas County, Florida.
This conveyance is subject to the condition that Grantee herein shall not assign or convey said property without the written consent
of the Grantor, and to the further condition that said property shall be used only for cemetery purposes as human burial sites and is
subject to such other rules and regulations the City of Clearwater may adopt pertaining to use of said property.
TO HAVE AND TO HOLD the same to the only proper use, benefit, and behoof of the said Grantee and their heirs and assigns
forever.
IN WITNESS WHEREOF, said Grantor has caused these presents to be executed in its name by its Mayor, by its City Manager,
and to be attested and its corporate seal affixed by the City Clerk on the day and year first above written.
Countersigned: CITY OF CLEARWATER, FLORIDA
Cke..0(1‘..fXrt\LICO
George N. Cretekos, Mayor
STATE OF FLORIDA )
COUNTY OF PINELLAS) -
Before me, the undersigned, personally appeared George N. Cretekos, the Mayor of the City of Cl arwatterry - on , well
known to be the person who executed the foregoing instrument and acknowledged the execution thereof to be er`fiee k5.4fid deed
for the use and purposes herein set forth.
Attest:
Nicole Sp`ag e, leputy Ci
WITNESS my hand and official seal this 7 day of Nave.> Jett- 2017.
4,016 Pt* Notary Public State of Florida
Ar ; Patricia A Kuligowski
• My Commission GG 131393
�?awf Expires 10/20/2021
Print/type name: /7Lf /� u /3O (d),S Notary P
is
STATE OF FLORIDA )
COUNTY OF PINELLAS) we, -"c c n,.9 TAc +C
Before me, the undersigned, personally appeared , the City Manager of the City of Clearwater, Florida, to me
well known to be the person who executed the foregoing instrument and acknowledged the execution thereof to be his free act and
deed for the use and purposes herein set forth.
WITNESS my hand and official seal this Corday of NUNtt,r4A -4i 2017.
Approv�d�s to for
P P.% SANDRA HARRIGER
''C� MY COMMISSION # FF930375
oF EXPIRES: January 04, 2020
Paul Richard Hull, Assistant City Attorney
CEMETERY DEED.DOC
RETURN TO: Official Records & Legislative Services
P. O. Box 4748, Clearwater, FL 33758
Print/type name:
5��1� ' �' t rL 2 r°
Notary Pub is
9700 -0026
Rev. 7/17
TERRY D CLARK
PATRICIA J CLARK
Ph. 727 -442 -3021
1428 S Hillcrest Ave
Clearwater, FL 33756
PAY TO THE
ORDER •F 0 (� QArid
/l
4& REGIONS
FOR CbVY1CrOtt7 (A7
1:063 L046681: 0 L598380 2?"
192
63- 466/631
/D --3 0 - 2GIE7
$ r3 1432.2
DOLLARS
LaCosse, Judith
From: Tokar, Mark
Sent: Monday, November 27, 2017 8:32 AM
To: LaCosse, Judith
Cc: Anderson, Matthew; DeWitt, Brian; Vaughan, Karen
Subject: Re: Cemetery Staking for Urn Burial
Yellow flags.
Get Outlook for iOS
On Wed, Nov 22, 2017 at 12:18 PM -0500, "LaCosse, Judith" < Judith .LaCosse @myClearwater.com> wrote:
Mark,
I received a cemetery staking request this afternoon from Joe Gambino of Moss Feaster Funeral Home for an urn burial.
Please stake Block 14, Lot 405, Space 00 (urn space) for burial of Patricia Ann Clark by next Thursday, November 30th.
DOB: 7/26/1948 DOD: 11/2/2017
The actual date of burial is scheduled for December 2nd at around 2:00 p.m.
If you have any questions please give me a call at 727 - 562 -4093.
Please let me know the color of the flags being used so that I could notify the funeral home.
Thanks.
Judith LaCosse
Staff Asst
City of Clearwater
ORLS Dept.
727 -562 -4093
1
MOSS FEASTER FUNERAL HOME
AND CREMATION SERVICES
693 SOUTH BELCHER ROAD
CLEAR WATER, FL 33764
(727) 562 -2070
PAY TO THE
ORDER OF
City of Clearwater
-- -Sixty And 0 /100 --
MEMO
Clark ---Sta ki ng - -F-ee-
0467300156711' 1:06L1127881: 0033598L005L0
BANK OF AMERICA
64- 1278/611
IOU
11/9/2017
60.00
DOLLARS
VOID AFTER 180 DAYS
CHECK CANNOT EXCEED $10,000.00
TWO SIGNATURES NEEDED IF OVER $5,000.00
AUTHORIZED SIGNATURE
MOSS FEASTER FUNERAL HOME AND CREMATION SERVICES
Comments
Clark Staking Fee
MOSS FEASTER FUNERAL HOME AND CREMATION SERVICES
L# Comments
1 Staking Fee
2 Staking Fee
Total forClark Staking Fee
riuELUXE CORP" 1 +800- 328 -0304 www.deluxeforms.com
_
881064 / 03-16
1567
Amount
60.00
60.00
1567
Amount
30.00
30.00
60.00
T::a
CLEARWATER CARETAKER
CLEARWATER, FL
Main Report V
BURIAL PERMIT
PERMIT # 1467
December 19, 2017
100% V
Permission is hereby granted for burial of:
Name of Deceased: PATRICIA A CLARK Burial Type: URN
Owner of Property: TERRY D CLARK &
Block : 14 Lot: 405 Space: 00 Date of Birth: July 26, 1948
Date of Death: November 2, 2017 Date of Burial: December 2, 2017
Funeral Home Director: JOE GAMBINO
Time: 14 :00 Staking Fee: 30.00
Date Paid: November 13, 2017
Clearwater Cemetery
By i�l tt