Kelleher, Dell Valentine .FROM , (TUE)MAY 1 2012 8:48/ST. 8:49/No.7500000552 P 2
AFFIDAVIT
STATE OF FLORIDA)
COUNTY OF PINELLAS)
I, Dell Valentine Kelleher,the undersigned,do hereby attest that I am the descendant of Wilson
H. 8 Modelle E.Valentine,my grandparents,who are buried in Spaces 2&3 of Block 7,Lot 82
and the owners of Block 7, Lot 82, Spaces 1 through 4 in the Clearwater Municipal Cemetery.
Please take this affidavit as your authority to assign interment rights in the vacant Space 1 in
Block 7, Lot 82 to myself. I authorize the interment of my brother,Kevin Patrick Kelleher,deceased,
in Space 1.
I understand that the maximum capacity of a space is two burials provided at least one person is
cremated.
i 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.
-IGNATURE ADDRESSIPHONE
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Dell Valentine Kelleher Ce ' f r
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SWORN TO and subscribed before me this /2/ day of i'3']A'/ , 2012 by Dell
Valentine Kelleher who produced identification in the form of FL DL 40.V-11g 1p(7 95e"•0 and
who did/did not take an oath.
SANDRA 4AI�CIA Notary Public
STATE OF 4/271ZU/II
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