Smith, Barbara Harris,1090] ,
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J
'TER
DEPARTMENT OF THE
CITY CLERK
Barbara Harris Smith
12512 Chronicle Drive
Fairfax, VA 22030
Dear Mrs. Smith;
CITY OF C LEARWATER
POST OFFICE Box 4748, CLEARWATER, FLORIDA 33758-4748
CITY MALI., 112 SOUTH OSCEOLA AVENUE, CLEARWATER, FLORIDA 33756
TELEPHONE (727) 562-4090 FAx (727) 562-4086
November 8, 2000
C?
Thank you for coming into our office today in order to provide me information regarding
interment rights granted to you and your family on behalf of your sister-in-law, Grace Harris. I
am enclosing a document that looks similar to the copy of the transaction granting the above
interment rights. This affidavit, however, authorizes the Clearwater Municipal Cemetery to note
in its official records that you have all right, title, and interest in the one remaining, unoccupied
space in property owned by your father, L. G. Harris, deceased.
Because we are not drawing a new deed at this time, the property will remain in your
father's name. Our records will indicate your right to the space and as such you have the
following choices:
1. You may dispose of the space by having our office draw Consent to Convey deed
between you and the new owner. You will be responsible to pay any administrative
fees and recording fees required by this office to affect the change of ownership.
2. You may grant right of interment to whomever you choose at no cost. You would
need to complete an affidavit instructing us who to grant interment rights to. The
affidavit would be similar to the one your sister-in-law, Grace Harris completed
granting rights in Block 7, Lot 128, Spaces 1 through 4 to you and your family
members.
If I can be of further service, please contact me.
Yours very truly,
Camille Motley
Central Records Specialist
cm
ONE CITY. ONE FUTURE.
BRIAN J. AUNGST, MAYOR-COMMISSIONER
J.B. JOHNSON, VICE MAYOR-COMMISSIONER BOB CLARK, COMMISSIONER
ED HART, COMMISSIONER ® ED HOOPER, COMMISSIONER
"FQU.v. FMPI,OYMFNT AND AFFIRMATIVE ACTION EMPLOYER"
November 7, 2000
AFFIDAVIT
Spaces 1, 2, 3, and 4 in Lot 129, Block 7, in the Clearwater Municipal Cemetery
are owned by L. G. Harris, Sr. Lemuel G. Harris, my brother; L. G. Harris, Sr., my
father; and Sallie B. Harris, my mother; are presently interred in spaces 1, 2, and 3 of
Lot 129, Block 7 respectively.
I, Barbara Harris Smith, the undersigned, do hereby attest that I am the daughter
and sole survivor of L. G. Harris, Sr., deceased, who is buried in Space 2, Lot 129,
Block 7. As sole survivor I have all right, title, and interest in the remaining, unoccupied
space, Space 4, in Lot 129, Block 7.
Please take this letter as your authority to note the right to property described as
Space 4, Lot 129, Block 7, to me, Barbara Harris Smith, in your records
I, further agree to release, indemnify and hold the City of Clearwater harmless
from liability in the event of any claim arising from the use of the property described
above.
SIGNATURE:
Barbara Harris Smith
12512 Chronicle Drive
Fairfax, VA 22030
SWORN TO and subscribed before me this day of , 2000, by
personally known to me or has made herself known to
me by
(SEAL)
(identification).
Notary
My commission expires:
.FULL NAME OF CHILD...... ......... ............. .... ..._.................................... L...... ...._ ..??!'??"° supplemental report, as directe .
0 4 (a) Twin• triplet, (b) Number in order t a Legit- ? 6 Date of
5 Sex o! or other? of birth imate;/
Chid birt _-- • 19 $-
{ ( - (Sion ) (Day) (Year)
To be answered only in event of plural births)
MOTHBR
ATHER - 13 FALL
'Fr I.I. MAID
NA11B
1 RESIDENCE 14 RESIDENCE G
4Csual Place of Abode) (Usual Place of Abode)
JLLX ?tIf \on-resident give I`lace and State
,if lion-resident give lace and State
110 AGE AT LAS 16 COLOIL OR/ 116 AGE AT LAST
9 COLOR OR BIRTHDAY ....___ ea s.)- BIRTHDAY _._......_..-._?-
RACE )' (YearaI
ii l3IItTHFLACE 17 BII2THPLA ac , I........
-__? -----
?..-?_. (City or Ple).__r.?-•
GCity or Place)__._._..__._.._.-_-....-__.._.-_.._-_...._..-.
(State or Country) (State or Country)
13 VCCCPATI 18 OCCUPATION -_?-
.........._
..... .....
1--Y ....._._ (Nature of I dustrY)
State of Florida i
Department of Health and Rehabilitative Services
BUREAU OF VITAL STATISTICS
NAME Calla Barbara Harris SEX -F
BIRTH DATE- July 3, 1922 UMBER109- 22-15939
BIRTH Hansberr
PLACE y- FLORIDA
RECORD Oct 15 s 1922 ISS
F D UED July 1 s 2987
This is a true certification of name and birth facts as recorded in this office.
(Not valid unless the Seal of the State of Florida,
Department of Health and Reh tatNe Services is 'xed.)
FIS Form 1084, Feb 84 B
ReDlaces ADr 79 edition) State R 9istrar of Vital Statistics MPH
_ ..? ?r..? z-j?' `r -_-'? $-rte; '? lore d-? k* °! ec? t r+v
ce of Birth State Board of Health of Florld(i Certificate of in '
REAU OF VITAL STATISTICS ' „J.',
.. ___.-___-_---_-. BU 15939
County r•----- •
1
Q File No----- _--_________-_--.-_____._-__--.?
Registration Distriet No....... _ ---• `
or * e nam not nu her)
Registered No. _ •_... ___ _
' im, Town. ........... primary Regletrutlon Dist. No. /---.......__...
of _ rd)
-•_ a
(NO...... _ _ _..._-----•--.st.f _............ __
C1tr--•••- ' - °" if 7i.r ccLrre to hospital r _ th __-_ er _ _?-in ? _stitution gt. a name instead of Ho_
41 it Child is not yet named. make
- _
3 Given name added rom
- -, 19-- 22 Filed / /J 1?' --=•
as or time f (af isu. r
1'! Xumber oP Children of this Mother (Taken
of R(rth of Child herein certified and including this child) I .and now
20 CERTIFICATE OF ATTEND
I hereby certify that I attended the birth of this child, who was..__...
on the date above stated.
f w?
' *?Vhen there wax no attending ph7si-
elan or midwife, then the father, home-
Molder, etc., should make this return. 21 (Signature)
stillborn child is one that neither
?hrenthex nor shows other evidence of
,life after birth.
a supplemental re- Address ----
f?
E
t,-'s - -- • No. l iPoat Office Address f %
?ai Ftegiatrar. Ferro V. S .._ _ ._..-.<.._ ?_ -.. .? .
CERTIFIED COPY
JUL i M7
THIS IS A CERTIFIED TRUE AND CORRECT COPY OF THE OFFICIAL RECORD ON FILE IN THIS OFFICE
s
F THE sr4r OLIVE . OORDE'
BY'A
ft-w ? "L- State Registrar
< c Office of Vital Statistics
i A
Vital RtCOI,tjA' t#)IIIiDAd<f4(41itJDz1HIS DOCUMENT IS PROHIBITED BY LAW. DO NOT
O ' s WARNING. ACCEPT UNLESS ON SECURITY PAPER WITH EMBOSSED GREAT SEAL OF THE STATE --_
' A???S?' OF FLORIDA. ALTERATION OR ERASURE VOIDS THIS CERTIFICATION. oFrnnn.?xr of Hrv.TM nno -
YYP\\\ ' RFJ?neurrnm•E sFxv?s ..:u
:j
c Alive (-b) Born Alive
w living .......... -but now dead. V_.-----•(e) Stillborn
!
TNO T YSICIAN" -41