Martin, JeanetteCemetery Call Work Sheet
Date: / (b / ac )'
Funeral Home / Monument Company: f' 14
Contact Name: ioL era Tel. #: �a►- `'t`�6- 3 °SSFax #: lid-f3- o`a5 °4
)tt Staking Request (Interment/Disinterment) Nlr. Qre,pd- 0112,Q c
Reason for call: g Re uest Interment/Disinterment ) L4 1.,z,‘
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
Owner of Plot: X1 t ` vtir.-
Deceased Name: � a-n e k ti C sf" +r )
Block /S Lot Space L1
Date of Birth: a- / o a/ 53
Date of Death
Date of Burial: 9 / 1(7/ d.-°)K
Time: I t ; ° O (am om
$30.00 Staking Fee (Funeral Home) — received on: � / 13 I 3°18
Copy of permit emailed to Mark Tokar, cc: Matt Anderson /P &R on: `1 / )3 / - o ig
******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
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 11/15/17
4A" 14-69
Re: Cemetery Staking - Urn Burial
Tokar, Mark
Wed 9/5/2018 7:57 AM
To:LaCosse, Judith <Judith.LaCosse @myClearwater.com >;
cc:Anderson, Matthew < matthew .anderson @myclearwater.com >; DeWitt, Brian < Brian .DeWitt @MyClearwater.com >;
Vaughan, Karen < Karen .Vaughan @MyClearwater.com >;
Orange flags.
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From: LaCosse, Judith
Sent: Tuesday, September 4, 2018 3:23:37 PM
To: Tokar, Mark
Cc: Anderson, Matthew; DeWitt, Brian; Vaughan, Karen
Subject: Cemetery Staking - Urn Burial
Mark,
We received a staking request from Bob Grant from Rhodes Funeral Home for a staking request for an Urn
burial for:
Jeanette Martin in Block 15, Lot 54, Space 3 DOB: 12/02/53 DOD: 08/15/18
Other burials nearby in this plot:
Space 1= Lillie M Williams - (full burial)
Space 2 = Clifford E Scott - (full burial)
Staking is needed by next Monday, September 10th at 11:00 a.m.
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
I
Status of Block: 15 Lot: 54 as of 09/04/2018
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED
1 FULL WILLIAMS LILLIE M 6/7/1922 10 / 21 / 1991 10/26/1991
2 FULL SCOTT CLIFFORD E 1/29/1948 03 / 13 / 1991 3/23/1991
DISINTERMENTS FROM SPACE:
No Matching Records
REINTERMENTS:
No Matching Records
Page 1 of 1
PERMIT
2024
1967
FLORIDA FAMILY
C. R E M A T I O N S
5840 Ulmerton Road
Unit D
Clearwater, FL 33760
Certificate of Cry ,inefit.qttoRDs AND
LEGISLATIVE S ', S DEPT
This is to certify that the remains of
Jeanette Martin
were cremated on the 23rd day of August, 2018, at Florida Crematory (License #085032) in a
professional and dignified manner.
Date of Death: 08/15/18 Permit Number:2018- F041686 -5011 File Number: 1992
Deb Davis Amy Rohr
Funeral Director in Charge Cremation Completed By
Sep.10.2018 09:29 ROYAL PALM NORTH 7275771937 PAGE. 1/ 1
State of Florida, Department of Health, Bureau of Vital Statistics
BURIAL TRANSIT PERMIT
FEU;
u
HEALTH DATE PRINTED: August 20, 2018 TRACKING NUMBER: 2018134178
1. DECEDENT INFORMATION
Name of Deceased Data of Death
JEANETTE MARTIN August 15, 2018
Place of Death - County City, Town or Location Name of facility, or stmt address If not a facility
PINELLAS PALM HARBOR EUNCOAET HOSPICE CARE CENTER NORTH PINELLAS
Name and Address of Funeral Home/Dlrect Disposal Establishment Fla. Llc. NoJReg. No. Phone Number
RHODES FUNERAL DIRECTORS INC F041686 F041686 (727) 446-3055
800 EAST DRUID RD
CLCARWATER, FLORIDA, 33756
Funeral Directorlblrect Disposer Era. Lk. No. /Rog. No.
ROBERT S. GRANT JR F043193
Medical Verification Statement
Cynthia at the certifying physician's office, was contacted on 08/16/2018 by the funeral director listed above; he /she indicated that
DAVID RICHARD DOERINGER, certifying physician, will complete and aign the medical certification of cause of death within 72
hours.
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: 201A.F041686 -5011
Date Issued: August 16, 2018
State Registrar
3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL- AT-SEA, or HOSPITAL DISPOSITION
Authorization given by Medical Examiner District 6 Approval Number: 71809845
4. CEMETERY OR CREMATORY
Place of Disposition: FLORIDA CREMATORY
Method of Disposition: CREMATION 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.
OH 326E, 10/12
64V- 1.011, Florida Administrative Code
OFFICIAL RECORDS AND
LEGISLATIVE SRVCS DEPT
080971'12-04
PAY TO THE
ORDER OFD
WORK & SON INC
2600 GANDY BLVD
ST. PETERSBURG, FL 33702
Up,61Awiord&A
MEMO 1-1 .0Tralailt
WELLS FARGO BANK, N.A.
WELLSFARGO.COM
55056
63 -751 /631
THANK YOU FOR YOUR SERVICE RV
•
00005505611' 1:063 LO L31:20006 258 L6 23711'
DOLLARS
N
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�,s �'pRWATfp'
° = CITY OF CLEARWATER
• �; POST OFFICE Box 4748, CLEAR'.\A1ER, FLORID 33758 -4748
■ 4
CITY HALL, 112 Sol i• I! OSCEOLAAVENEE ,CLEARNATER,FLORIDA 33756ss* TELEPHONE (727) 562-4090 FAX (727) 562-4086
— r-4eGSHEOl��ii/ 1/1 {{
OFFICIAL RECORDS AND
LEGISLATIVE SERVICES
September 13, 2018
Work & Son Inc
2600 Gandy Blvd
St. Petersburg, FL 33702
To Whom It May Concern:
We received your Cemetery Staking Fee check #55056 in the amount of $30.00
for the interment of Jeanette Martin.
Attached you will find receipt No. 449075.
Thank you,
gdith LaCosse
taff Assistant
(Encl.)
"Equal Employment and Affirmative Action Employer"