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Brush, CharlesDate: ' / / 0 )_0 Cemetery Call Work Sheet Funeral Home / Monument Company: 3 05 Contact Name: /c."'ra s1i Tel. #: 3 }- 3'i 3 Fax #: Reason for call: Staking Request (Interment/Disinterment) Affidavit (Burial Rights) c- :ayj1 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: CLQ (;recd Deceased Name: Block Co Lot 13 Space Date of Birth: / / Date of Death / / Date of Burial: / / Time: am/pm $30.00 Staking Fee (Funeral Home) — received on: / / Copy of permit emailed to Nathan Brigman, 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 6/2/2020 INTERMENTS BURIAL SP TYPE 1 FULL 2 FULL 3 URN 3 FULL 6 FULL 7 FULL 9 FULL 10 FULL 13 FULL 14 FULL DECL BRUSH BRUSH GARLAND BASSETT WHITTLE WHITTLE BRUSH BRUSH WHITTLE WHITESELL DISINTERMENTS REINTERMENTS Status of Block: 6 LOT: 13 as of 8/3/2020 DECF DECM BIRTH DEATH INTERRED PERMIT CHARLES H 1/1/1867 SARAH L 1/1/1842 BETH B 6/27/1907 MAE B 1/1/1872 J C 4/27/1851 ANNA E 9/22/1853 CLARE S 1/19/1904 CAROLYN L 3/5/1905 WILLIAM J 8/31/1872 ALICE C 1/1/1876 1/1/1937 1/1/1921 11/3/1995 10/30/1957 8/29/1921 6/15/1931 4/3/1962 3/14/1983 5/14/1933 1/1/1951 1/1/1937 1/1/1921 11/18/1995 10/30/1957 8/29/1921 6/15/1931 4/4/1962 3/16/1983 5/14/1933 1/1/1951 0 0 2234 1303 0 0 183 1509 0 0 STATE OF FLORIDA) COUNTY AFFIDAVIT We, , the undersigned, do hereby attest that we are the descendants of Charles Brush, our Great Grandfather, who is buried' in Block 6. Lot 13, Space 1 and was the owner of Spaces 1, 2, 3, 4, 9, 10, 11 & 12 in the Clearwater Municipal Cemetery. Please take this affidavit as your authority to assign interment rights in Block 6, Lot 13, spaces ( ) to myself Donald Brush and my sister, Patricia Brush Outlaw. We agree to release, indemnify and hoed the City of Clearwater harmless from liability in the event of any claim arising from the use of the above described Property as stated above. SIGNATURE ADDRESS/PHONE on ld B►ush G Patricia Brush Outlaw 3 o nId 5'S sr A N Rte P. CARtlANA * * MYOOk OW![I(iOININT rte 4, -LZ 1 !' . -4/'Y7 �� soma Ree a Q.�tt erN -2' 1 a r ovsic ra-' .4L'* * ii /ckii host (, t - it *o# SWORN TO and subscribed before me Donald Brush the form of 17 k:ic/v... L ie e r.'...f J ar • SWORN TO and subscribed before me by Patricia Brush Outlaw the form of doe LIK,orttrisr� r this .2.4? day ofsrr•-,R, tc>Z p who produced identification In and who did/did not takean oath. this 22,ry' day of rFfreMe e� z p who produced identification in and who did/did not take an oath. Notary Public FAMHi¥= Y ncr ori limr' child fiOr O 17.2 0 CEITIFiCArE 07 CORQNt o•-• #4:-.1Ai Pa ' Bruch „ lut it Of- Of A t : t= A r • t October 15, 1979 C:41G114 OR CiC.E.N wr 1 Ail( - L ALT ' L, NIt,..e, I ...I,. Di- q. oF E,Et i ts -.N. ,Wock E. ..:= 7 r -7 A I— Ctlf, IN ; * Or i 1, A I itt. i VOL iLt . , .ott f ts - 7 s 0 ,'"r 01 if i A 714 ,illne 2 , 1921 .. El Paso i- Colorado E.-. pr i rigs ,,. Penrose Hospital .i , Emer. Fly': _ .......- ------- :' T: t" f: f.:1) ......** .. 1" f•ff iStPITAL OR ()THEN o-‘ , ! ITU 710f1 - no no 11+.1.5t V. 1 IRIF. .41+4 t“." .. -,' '...,.110., # ,..., ........... ............., , — ,... .. .............---....... . — —...... 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CC ffm t - 7 _ "•.,* • LrCri ttr, ArR ,),"Ltrtiirt,t ,41 , -4. 1 1 O,V 114. - ^,11 7 t t or4 Ittet.t, ' L OcL 16 19 9 tja wards 1 nera Eome Fort Sri „ ns a s .—„ • ir — --Tott <tcirs 7311 301 oz. 0. .-pgs. man - Robert' th c•Jb e 1S,1973 _ — 0„,0rtr1 -- ___,t.-1L rt".. •ttr tt` D • - 1- D ;rft•r, •••• ',", rt'ti • - -7 - 2O Nr40. V „.„,„ ar, f Cemetery Call Work Sheet Date: 7 / /S / a o I I Funeral Home / Monument Company: Contact Name: 20 1M aru CIO►,nieictpQ oo •cow,. Tel. #: 305 ) - 30a- ro353 Fax #: 1 dddJ as° si CNA., Reason for call: Staking Request (Interment/Disinterment) Pa:tr et 8r 0al.' r Affidavit (Burial Rights) Monument (Marker) being placed (No fee for staking of monument) Ow k.c.4: Cit.4412-#.4 �r�s L , T"Rc-1/ k�fd l..*t, ✓ Verifying Burial space Grukd falikeit. = Cl S. Brush,. Other reason: Interment: (One full burial and one urn, or two urns per space) Full Burial ,,i Urn Space Owner of Plot: Cre� rk.s Deceased Name: Block (0 Lot ( 3 Space Date of Birth: / / Date of Death Date of Burial: / / Time: am/pm $30.00 Staking Fee (Funeral Home) - received on: Copy of permit faxed to Joe Taylor/P&R - Fax No. 6551 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 1/51li - «�ete . dots . bokc.,QJ fink sk . Revised 6/29/11 (S.2A. Alf.,a.. ) Cemetery Tracking System Page 1 of 1 "iT Good Afternoon!Today is Friday,July 15, 2011 Home I Feedback You are logged in as Judith.LaCosse Cemetery Cemetery Tracking System - View Lot Profile 8 File Transaction Block: 6 Lot: 13 View Lot Profile Profile Summary Click 'View Assigned' to view interment details. If more than one individual is interred in a space, a © Reports second grid will appear below,displaying all of the individuals assigned to the space. Click'View' on Print Burial the second grid to view the interment details of that individual. Permit Search Names 'EAST SIDE OF MYRTLE AVENUE -- ....._ and Notes (Space Owner Last Owner First Owner Middle Max Interred Total Assigned Interred 1 BRUSH CHARLES 1 1 1 View Assigned Search Old Locations 2 BRUSH CHARLES 1 1 1 View Assigned 13 BRUSH CHARLES 2 2 2 View Assigned. Print/View Lot 14 BRUSH CHARLES 0 0 0 View Assigned Status i 5 WHITTLE OWNER - 0 0 0 View Assigned Monthly Memo 6 WHITTLE OWNER - 1 1 1 View Assigned 7 WHITTLE OWNER - 1 1 1 View Assigned Disinterments 8 WHITTLE OWNER - 0 0 0 View Assigned Deceased by 9 BRUSH CHARLES 1 1 1 View Assigned Location 10 BRUSH CHARLES 1 1 1 View Assigned Alphabetical List of Deceased File 1 2 List of Owners File Reinterments Permits List by Deceased . Permits List by 1 Location PRBurial i I 8 Maintenance i Control Data Valid Locations Security [ Previous Page] — [Too of Page] Updated on Tuesday,January 06, 2009 Home I Feedback I Departments I Contacts I Forms http://clearwater/Apps20/cemetery/viewlotprofile.aspx?b=6&1=13 7/15/2011 Cemetery Tracking System Page 1 of 1 CliT(w C'4M11wAT117 ��� ...~�•••• rt -- LN r J T T Good Afternoon!Today is Friday,July 15, 2011 Home I Feedback You are logged in as Judith.LaCosse 8 Cemetery Cemetery Tracking System - View Lot Profile 8 File Transaction Block: 6 Lot: 13 View Lot Profile Profile Summary Click'View Assigned'to view interment details. If more than one individual is interred in a space, a 8 Reports second grid will appear below, displaying all of the individuals assigned to the space. Click 'View' on Print Burial the second grid to view the interment details of that individual. Permit Search Names (EAST SIDE OF MYRTLE AVENUE and Notes Space Owner Last Owner First Owner Middle Max Interred Total Assigned Interred 11 BRUSH CHARLES 0 0 0 View Assigned Search Old Locations 112 BRUSH CHARLES 0 0 0 View Assigned 13 WHITTLE OWNER - 1 1 1 View Assigned Print/View Lot 114 WHITTLE OWNER - 1 1 1 View Assigned Status 15 WHITTLE OWNER 0 0 0 View Assigned - Monthly Memo 16 WHITTLE OWNER - 0 0 0 View Assigned Disinterments - 12 Deceased by Location Alphabetical List of Deceased File List of Owners File Reinterments i Permits List by Deceased Permits List by Location PRBurial s Maintenance i Control Data Valid Locations Security [ Previous Page] — [Too of Page] Updated on Tuesday,January 06, 2009 Home I Feedback I Deoartmen s I Contacts I Forms http://clearwater/Apps20/cemetery/viewlotprofile.aspx?b=6&1=13 7/15/2011 1 Status of Block: 6 Lot: 13 as of 07/05/2011 INTERMENTS: SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED PERMIT 1 FULL BRUSH CHARLES H 1/1/1867 01 /01/1937 1/1/1937 0 2 FULL BRUSH SARAH L 1/1/1842 01 /01 / 1921 1/1/1921 0 1 3 URN GARLAND BETH B 6/27/1907 11/03/ 1995 11/18/1995 2234 3 FULL BASSETT MAE B 1/1/1872 10/30/ 1957 10/30/1957 1303 6 FULL WHITTLE J C 4/27/1851 08/29/1921 8/29/1921 0 7 FULL WHITTLE ANNA E 9/22/1853 06/ 15/1931 6/15/1931 0 9 FULL BRUSH CLARE S 1/19/1904 04/03/1962 4/4/1962 183 10 FULL BRUSH CAROLYN L 3/5/1905 03/ 14/ 1983 3/16/1983 1509 13 FULL WHITTLE WILLIAM J 8/31/1872 05/ 14/1933 5/14/1933 0 14 FULL WHITESELL ALICE C 1/1/1876 01 /01 / 1951 1/1/1951 0 DISINTERMENTS FROM SPACE: No Matching Records REINTERMENTS: No Matching Records may,/GO frown 8)o Gk 6, Lot 3 sd. 3 Bets .11. G Q€P,d2 - grad- 1L. M 4 e a . 3 444 elf- 110+LA. J No-fe: Lh'fe.te.-'f r .-e - et, o,.. tie .Fq, 4 IA 8rksI, 11wh,Q, Page 1 of I AFFIDAVIT STATE OF FLORIDA) COUNTY OF PINELLAS) We, _, the undersigned, do hereby attest that we are the descendants of Charles Brush, our Great Grandfather, who is buried in Block 6, Lot 13, Space 1 and was the owner of Spaces 1, 2, 3, 4, 9, 10, 11 & 12 in the Clearwater Municipal Cemetery. Please take this affidavit as your authority to assign interment rights in Block 6, Lot 13, spaces ( ) to myself Donald Brush and my sister, Patricia Brush Outlaw. We 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 above described property as stated above. SIGNATURE ADDRESS/PHONE Donald Brush Patricia Brush Outlaw SWORN TO and subscribed before me this day of by Donald Brush who produced identification in the form of and who did/did not take an oath. SWORN TO and subscribed before me this day of by Patricia Brush Outlaw who produced identification in the form of and who did/did not take an oath. Notary Public My commission expires: