Newsome, Helen (2)Cemetery Call Work Sheet
Date: '3 / 2- I / 1 q
Funeral Home / Monument Company: M� ss �ea s"Cer'
Contact Name: c)oe. Tel. #: S b a - a-° -7 ° 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)
Verifying Burial space
Other reason:
fikic f9a
041 (544_1_ tiotn-R-
Interment: (One full burial and one urn, or two urns per space)
Full Burial `7
Owner of Plot:
Urn Space
14eQ.eh Ne-GOsow,
Deceased Name:
CAA) S on -4.,
Block 1 a-- Lot 10 Space i
Date of Birth: 3 / 19 / (0-1 Date of Death V / 2-I / 19
Date of Burial: S / a3 / 19 Time: 0 am/pm
at c 1c 4s- (q (fa - PIbs 5
$30.00 Staking Fee (Funeral Horne) — received on: $ / a& / a.o 19 rp4„-fer
Copy of permit emailed to Mark Tokar, cc: Matt Anderson/P&R on: / / -Per 1.-'a 4* / `f 7y
**************************************************************************************************
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
LaCosse, Judith
From:
Sent:
To:
Cc:
Subject:
LaCosse, Judith
Wednesday, August 21, 2019 1:57 PM
Tokar, Mark
Vaughan, Karen
RE: Rush Cemetery Staking - Full Burial
Thank You !! 1 will notify the funeral home.
From: Tokar, Mark <Mark.Tokar@myClearwater.com>
Sent: Wednesday, August 21, 2019 1:11 PM
To: LaCosse, Judith <Judith.LaCosse@myClearwater.com>; Anderson, Matthew
<matthew.anderson@myclearwater.com>
Cc: Vaughan, Karen <Karen.Vaughan@MyClearwater.com>
Subject: Re: Rush Cemetery Staking - Full Burial
Pink flags.
Get Outlook for iOS
From: LaCosse, Judith <Judith.LaCosse@mvClearwater.com>
Sent: Wednesday, August 21, 2019 11:16:44 AM
To: Tokar, Mark <Mark.Tokar@myClearwater.com>; Anderson, Matthew<matthew.anderson@mvclearwater.com>
Cc: Vaughan, Karen<Karen.Vaughan@MyClearwater.com>
Subject: Rush Cemetery Staking - Full Burial
Mark,
We received a cemetery staking request this morning from Joe of Moss Feaster Funeral Home for a full burial.
Please stake Block 12 Lot 10, Space 4 for a full burial.
Deceased Name: Helen Newsome - DOB: 03/19/1927 DOD: 08/21/2019
Burial is scheduled for this Friday, August 23rd and not sure of the time, still checking with the family.
Other burials nearby in Block 12, Lot 10:
Space 1= J H West - full burial
Space 2 = Mabel L West - full burial
Space 3 = Basil W Newsome — full 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
1
1.
Name of Deceased
HELEN V NEWSOME
State of Florida, Department of Health
BURIAL T 'Bureau of Vital Statistics
DATE PRINTED: August 23, 2019 TRANSIT PERMIT
DECEDENT ITRACKING NUMBER: 2019137058
INFORMATION
Place of Death - County
PINELLAB City Town or Loc Date of Death
Name and Location August 21,
Address CLEARWATER 2019
MOSS- of Funeral Home/Direct Name of facility, or street address H
693 SOUTH BELCH Establishment 2486 BELL not a faculty
CLEARW ER RD AND CREMATION SERVICES EAIR ROAD
ATER FLORIDA, 33764 ES F080439 Fla. Lic, No./Reg. Funeral Director/Dir F080439 No.
Director/Direct DisposerPhone Number
JOSEPH GAMBINO (727) 562-2070
Medical Verification Statement
KIM at the certifying
MICHAEL PHILIP physician's
�R i Cert office, was Contac Fla.
WAN Lic. No./Reg. No.
ung physician, willcomplete n X22/2019 by the F036947
and sign the medicaeral � certification se of atnhdicated that
within 72 Hours.
The Florida Department of Health - -
permission to dis 'Bureau of Vital Statistics
hereby grants
pose of this body in accordan
Ce with Chapter 382, Florida Statutes.
�4 Permit Number:
2019-F080439-5169
3. Date Issued:
AUTHORIZATION for CRE State Registrar August 21, 2019
Authorization CREMATION, DIS
given by Medical SECTION, BURIAL-
Exantiner District
4. AT -SEA, or HO`
PITAL DISPOSITION
Place of Disposition: Approval Number:
Method of i $osition: CEMETERY
CLEAL ATER MUNICIPAL CEMETERY
Disposition: OR CREMATORY
EDR$ BURIAL
maintains all statutorily re
burial transit permit Date of Disposition:
longer re ,therefor required information regarding the position: —_
required. e, returning gardin
If the Place permit to the death record and related
DH 326E, 10/12of Final Disposition county
sav-1.011, Position wishe Y health department
Florida Administrative Code s to retain the is no
copy of the permit for their file they may do so.
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
---Thirty And 0/100 ---
MEMO
Newsome Stacking Fee
BANK OF AMERICA
64-1278/611
1942
8/22/2019 i
30.00
DOLLARS
VOID AFTER 180 DAYS
CHECK CANNOT EXCEED $10,000.00
TWO S ATURES NEEDED' VER $5,000.00
AUTHORIZED SIGNATURE
8
II' 4 6 7 300 i 9 4 211' 1:06 L 27884 00 3 3 5 98 L00 5 ie
IOSS FEASTER FUNERAL HOME AND CREMATION SERVICES 1942
Comments
Newsome Stacking Fee
Amount
30.00
30.00
IOSS FEASTER FUNERAL HOME AND CREMATION SERVICES 1942
Li Comments Amount
1 Newsome Stacking Fee 30.00
Total forNewsome Stacking Fee 30'00
InDauoa COer 1+800-328-0304 www.deluxeforms.com
e01004/03.16
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