Polachnik, JosephineDate: / / '1-°1
Funeral Home / Monument Company:
Contact Name: KotieJ 1 �r 4
Cemetery Call Work Sheet
Tel. #: 3a1 -4`t1 -3°55 Fax #: 7. -i - Lf`f3 - 0
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)
Verifying Burial space
Other reason:
**************************************************************************************************
Interment: (One full burial and one urn, or two urns per space)
Full Burial ✓ Urn Space
Owner of Plot: ;�o�.zo Qac%►,,t k
Deceased Name: Po.l?tic�v� k
Block 1L Lot ? Space 6 -
Date of Birth: 04 / 9-1/ a (v Date of Death / / 19
Date of Burial: &6/")f /
y a S�c�c1,n-ii�
,Jo,.k (� ��� /�� Sfce
Time: am/pm 0
SEA kAi 4t N '7 r
$30.00 Staking Fee (Funeral Home) — received on: / / � / a -O 19 (W k `)
Copy of permit emailed to Mark Tokar, cc: Matt Anderson/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 11/15/17
1
Re: Cemetery Staking Request for Full Burial
Tokar, Mark
Tue 6/18/2019 7:08 AM
To LaCosse, Judith <Judith.LaCosse@myClearwatercom>;
cc:Anderson, Matthew<matthew.anderson@myclearwatercom>; Vaughan, Karen <Karen.Vaughan@MyClearwatercom>;
White flags.
Get Outlook for iOS
From: LaCosse, Judith
Sent: Monday, June 17, 2019 4:03:53 PM
To: Tokar, Mark
Cc: Anderson, Matthew; Vaughan, Karen
Subject: Cemetery Staking Request for Full Burial
Mark,
We received a cemetery staking request this afternoon from Robert Grant of Rhodes Funeral Home for a full burial.
Please stake Block 16, Lot 28, Space 2 for a full burial.
Deceasec; Name: Josephine Polachnik - DOB: 02/21/26 DOD: 06/16/19
Note: Mr. Grant is still checking with the family to verify the interment date and he wanted the space marked.
Other burials nearby in Block 16, Lot 28:
Space 1= Anthony Polachnik (husband) - full burial
Space 3 = Beth Stockman - full burial
Space 3 = John Stockman - urn burial
Please let me know the color of the flags being used so that I could notify the funeral home.
If you have any questions please give me a call at 727-562-4093.
Thanks !!
Judith LaCosse
Staff Asst
City of Clearwater
ORLS Dept.
727-562-4093
State of Florida, Department of Health, Bureau of Vital Statistics
ii i BURIAL TRANSIT PERMIT
HEALTH DATE PRINTED: June 17, 2019 TRACKING NUMBER: 2019100358
1. DECEDENT INFORMATION
Name of Deceased Date of Death
JOSEPHINE POLACHNIK June 16, 2019
Place of Death - County City, Town or Location Name of facility, or street address if not a facility
PINELLAS PALM HARBOR SUNCOAST HOSPICE CARE CENTER NORTH PINELLAS
Name and Address of Funeral Home/Direct Disposal Establishment Fla. Lic. NoJReg. No. Phone Number
RHODES FUNERAL DIRECTORS INC F041686 F041686 (727) 446-3055
800 EAST DRUID RD
CLEARWATER, FLORIDA, 33756
Funeral Director/Direct Disposer Fla. Lic. No./Reg. No.
ROBERT S GRANT JR F043193
Medical Verification Statement
Dee at the certifying physician's office, was contacted on 06/17/2019 by the funeral director listed above; he/she indicated that
KARLA RAE POPE, certifying physician, will complete and sign 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.
r�K' Permit Number: 2019-F041686-5011
KDate Issued: June 17, 2019
State Registrar
3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL-AT-SEA, or HOSPITAL DISPOSITION
Authorization given by Medical Examiner District Approval Number:
4. CEMETERY OR CREMATORY
Place of Disposition: CLEARWATER CITY CEMETERY
Method of Disposition: BURIAL 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.
DH 326E, 10/12
64V-1.011, Florida Administrative Code
PAY TO THE
ORDER OF
WORK & SON INC.
DIP ACCOUNT
(727) 577-0599
2600 GANDY BLVD
PINELLAS PARK, FL 33702
MEMO
P
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WELLS FARGO BANK, N.A.
WELLSFARGO.COM
$
THANK YOU FOR YOUR SERVICE
679
63-751/631
DOLLARS
11.0006 7911' '1:06 3 L0 7 S L 3D: 7 5 5 2 3889 56e
CLEARWATER CARETAKER
CLEARWATER, FL
Permission is hereby granted for burial of:
Name of Deceased: JOSEPHINE POLACHNIK
Owner of Property: JOSEPHINE POLACHNIK
Block: 16 Lot: 28
BURIAL PERMIT 8/5/2019
PERMIT # 1471
August 5, 2019
Burial Type: FULL
Space: 2 Date of Birth: February 21, 1926
Date of Death: June 16, 2019
Funeral Home Director: ROBERT GRANT/RHODES
F.H.
Time:
Date of Burial: June 24, 2019
Staking Fee: $30.00 Fee Paid: 8/5/2019 12:00:00 AM
Clearwater Cemetery
By --
11,t �L C. �--
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