Olsen, Agnes
Date: 4I / ??
Cemetery Call Work Sheet
Funeral Home: ?S Monument Company:
Contact Name: Contact Name:
Tel. ?Y(-e a 3?S Tel. #•
Fax #:
12E: s P-DC-1, "'-?
Fax #:
Deceased Name: DOD:
Owner of Property:
_? r?-?? CZ
Block 1 `C Lot 39? Space CX-D
` t 4 (P DOB:
Interment: Full Burial:
($30.00 Staking Fee) - (One full burial and one urn, or two urns)
Date of Burial: Xc?
T
ime: a pm
Urn Space: 1Disinterment:
7
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
Monument Being Placed:
(No Fee for Staking of Monument)
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` Vaughan, Karen
From: Vaughan, Karen
Thursday, February 09, 2006 9:58 AM
Sent:
'cliff.stewart@sci-us.com'
To: Cc: 'kristie.gunterman@sci-us.com'
Agnes Oleson / Clearwater Cemetery
Subject:
Hello! signatures today and it is now on its way to the Courthouse to be recorded. It
I received the deed back with all appropriate will be mailed to Bertha Gornowicz. I spoke with
will then be sent back to the City (Official Records) for filing and a copy
rtha toda and told her that it's fine to go ahead with the burial of Agnes Oleson. I believe you are already in possession
Be y
of the ashes.
liff, if ou would, please contact Bertha at 727-399-0860 to set a date and time for the burial. I previously faxed you a
C Y
copy of the map with the space indicated.
Block 14 / Lot 393 / Space 00 - Urn space. Let me know when I need to have the space flagged.
(Let me know if you need the map faxed again because I know it's been awhile.)
Thanks!
Karen Vaughan
Sr. Staff Assistant
Official Records and Legislative Services
Phone: 727-562-409
karen.vaughan@myclearwater.com
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CEMETERY DEED
THIS INDENTURE made this 26th day of January , 2006, between the City of
Clearwater, Florida, a municipal corporation as Grantor and BERTHA GORNOWICZ, whose
mailing address is 11226 82nd Ave. N.. Apt. 102. Seminole. FL 33772 County of Pinellas, State
of Florida, as Grantee:
WITNESSETH: That the said Grantor, for and in consideration of the sum of $125.00 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: SPACE zero (00), LOT Three Hundred Ninety Three (393), BLOCK Fourteen (14),
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.
Counte igned: CITE OF GLEARIGVA LORI
B
,_Fr k V. Hibbard, Mayor Williar;i)B. "e,,,1L? ity Manager
Mary K. Dilrtssistant City Clerk
STATE OF FLORIDA ) l
COUNTY OF PINELLAS)
Before me, the undersigned, personally appeared Frank V. Hibbard, the Mayor 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 her free act and deed for the
use and purposes herein set forth.
WITNESS my hand and official seal this day of"' .?; 2006. \
Y' Ise A. Wilson
Deni
* Commission # DD296233 • Notary Public
Expires June 18, 2008
for aandedrmr??n•inw IMM;7et9 Print/type name:. _ ' 1.?1?f j srZ L ?
STATE OF FLORIDA )
COUNTY OF PINELLAS)
Before me, the undersigned, personally appeared William B. Horne, II, 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 day o ICI ,-2006.
Y pDenise A. Wilson rlotary P?blic
* Commission # DD296233
OF :'E
N e 18,2008 Print/type name:.'
xpires un
ded Troy Fain Inlurln0e, Ino: @90.2@5 7019
Ap d as to form:
711/
Pamela K. Akin, City Attorney
CEMETERY DEED.DOC 9700-0026
RETURN TO: Official Records & Legislative Services Rev. 1/06
P. O. Box 4748, Clearwater, FL 33758
CITY OF CLEARWATER
Interdepartment Correspondence
TO: LEGAL DEPT. 1. MAYOR
FROM: OFFICIAL RECORDS & LEG. SVCS. 2. CITY MANAGER
SUBJECT: CEMETERY DEED 3. CITY ATTORNEY
DATE: January 26, 2006 4. ASST. CITY CLERK
(X) FOR YOUR SIGNATURE
Bertha Gornowicz - Block 14/Lot 393/Space 00
Thank you.
udith LaCosse
Staff Assistant
.............
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CITY OF CLEAR WATER Date: ??aooC o
PURCHASE OF CEMETER Y SPA CE CHECKLIST
OWNER'S NAME eY4-1-? r?now' c -2 PHONE NUMBER -7 344- oFS (oO
ADDRESS
BLOCK I L4 LOT 39 3 SPACE C?o
INTERRED: = CD COST OF SPACE $
RECORDING FEE -t z??ps $ 9C)
' ®p
STAKING FEE $ 0'
RECEIPT NO. TOTAL $ l 14- • 9t ?D
The Purchaser will first visit the cemetery and obtain the legal description of the space selected from the caretaker at the cemetery. The
following steps shall then be followed in their listed order.
k CheckAvailibility ofspace
' / Prepare a receipt and a copy of the Rules and Regulation for the purchaser
V Color in green plat (located in binder in overhead cabinet at receptionist's station)
\o1T1;: PC)I,L(?li'I,'`, °,'TI PS 1111-1 :T)LF,D BY EdII'LOlE1 S JV 0 ARE RO II/VEL)' IiT"S1"0zNS/1;',I; (;-i,r"z { '1 ? z I< 7? '
Ii ,-
- > PZ RC'K-t5€,. I I__ {SG SFE ":IUL)/T'l ),V,tL STI PS f (t.? ,I r <" I r'
,11 I L.-R,1II_;V71 ?^_1.3? r 1 C} l1(1i_('-1C;;_.
_ Input ownership information in database program for spaces in all Blocks. Additionally, write information in Ownership
Book (located in vault) for all spaces in Blocks I thru II only
V-Prepare deed for each space purchased
VPre are routing memo
Fill in Florida Dept. of Revenue form
Enter document information re deed in Document Tracking System
- Route deed and revenue form for signature -file check list in vault (28-003)
After deed is returned to Clerk Dept. fully executed, send for recording and enter necessary information in Document
Tracking System
-Upon return of deed from recording, pull check list from 28-003, mark completed in Document Tracking System, and enter
recording date and OR Book & Page number in Cemetery data base file
-Prepare transmittal letter and enclose the original deed and a copy of the Rules and Regulations and send to owner
File copy of deed, check list, and transmittal letter (attached in that order) in cemeteryfiles in vault by owner's last name in
28-001
ADDITIONAL STEPS FOR AT-NEED USE OF SPACE (INTERMENT)
Fill out burial permit (located in overhead cabinet at Receptionist's station)
-Fax permit to cemetery (6487) and Parks field house (6551)
-File permit in back of blue binder located in vault above the 28-000 files
-Prepare receipt when staking fee ($30.00) is received from Funeral Home
(mark in data base file and on paper copy of cemetery permit)
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487 359 231 2
379 251 123 110 485 357 229 4
381 253 125 108
483 355 227 6
383 255 127 106
481 353 225 8 \
385 257 129 104
479 351 223 10
387 259 131 102 -
477 349 221 12
389 261 133 100
4 75 347 219 14
391 263 155 98
473 345 217 16
393 265 137 96
471 343 215 18
395 267 139 94
469 341 213 20
397 269 141 92
467 339 211 22
399 271 143 90 D
465 337 209 24 z
401 273 145 88 W
463 335 207 26
403 2 75 147 86 Q
461 333 205 28
405 277 149 84
459 331 203 30
407 279 151 82
457 329 201 32
409 281 153 80
455 327 199 34
411 283 155 78 1
453 325 197 36
413 285 157 76 n/
451 323 195 38
415 287 159 74
449 321 193 40
417 289 161 72
447 319 191 42
419 291 163 70
445 317 189 44
421 293 165 68
443 315 187 46
423 295 167 66
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BURIAL PERMIT
CLEARWATER CARETAKER
CLEARWATER. FL
Permission is hereby granted for burial of:
Name of Deceased: AGNES OLSEN
Owner of Property: &
PERMIT # 2561
March 07, 2006
Burial Type: URN
Block : 14 Lot: 393 Space: 00 Date of Birth: January 28, 1925
Date of Death: January 15, 2006 Date of Burial: February 22, 2006
Funeral Home Director: CLIFF STEWART/MOSS FEASTER
Time: 15:00 Staking Fee: 30.00 Date Paid: January 18, 2006
Clearwater Cemetery
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