Culbertson, GayleCemetery Call Work Sheet
Date: I° / V1 / o i I
Funeral Home / Monument Company:
Contact Name: Phi .p elbert5o - cJbertsc .
Tel. #: Fax #: e .:.Q.: �1 2 � �c e M w� . co,
Reason for call: Staking Request (Interment/Disinterment)
Affidavit (Burial Rights)
Monument (Marker) being placed (No fee for staking of monument)
Verifying Burial spaces) -a,. Pkiar k 64e. C. Q l errts.
Other reason: '" B' `k ) L0 6
(0,1,c 8, of 6 y Sa,a
Mr. - Mrs. .
******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Interment: (One full burial and one um, or two urns per space)
Bdevck , Lot 69:
�� )
Space 1 = 6J:P1Qnek k.
sbkte a = Edna w4.51,1�4./tt1 Moo e
Full Burial Urn Space
Owner of Plot:
Deceased Name:
Edna Wck.Sk,h..
'Luc() 0.
Block Lot Space
Date of Birth: / / Date of Death
Date of Burial: / /
5p4_(44 3 a- 54 = V 4 c& t
S, i t '11 . h /�
C F l spcG2 'l G 1740 y (}.
M4ym.e A m-.. t3ecL LQiAir,f1
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
Revised 6/29/11
Sir Speedy
Printing and Marketing Services
f)/J// (, / 49 — off le Cul oil
Com
SQ'1dl pp/jl�u,Qi 1 f�,o -aui - �v� /�Qih� wish
`sA.0 G� A"-- S -I° Ml v •-\.. aQw.f?.
1V\19 owe -en- L4'1 )..b (, L k-ct_
1Y'0 , L0 `O I
L of `? .
L of 6 Si ce s 3 .4- '-f — U �w�
I
S A `LA 14 wt Moore
0.14AA K.W4 &M —
C. '& 1a, 'p4Le Rar,t Avutit 1:3c 1 e./ Gintf .
I t I = /4 cult. A. 131-4 I l .fJi ►12 cDr� iii
1878 Drew Street
Clearwater, FL 33765
S
sirspeeclyx2gearthlink.net
461 -5300
Fax 443 -0894
I
Status of Block: 8 Lot: 69 as of 10/19/2011
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED PERMIT
1 FULL WASHBURN WILLARD K 1/1/1907 01 / 01 / 1949 1/1/1949 0
2 FULL MOORE EDNA W 1/1/1907 02 / 23 / 1979 2/26/1979 1298
DISINTERMENTS FROM SPACE:
No Matching Records
REINTERMENTS:
No Matching Records
Page 1 of 1
Status of Block: 8 Lot: 70 as of 10/19/2011
r
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED PERMIT
1 FULL BECHTELHEIMER HARRY A 1/1/1878 10 / 21 / 1957 10/21/1957 1301
2 FULL BECHTELHEIMER MAYME A 1/1/1874 06 / 08 / 1965 6/8/1965 444
3 FULL EGAN JOHN M 1/1/1868 01 / 01 / 1950 1/1/1950 0
DISINTERMENTS FROM SPACE:
No Matching Records
REINTERMENTS:
No Matching Records
Page 1of1
4P
LaCosse, Judith
From: LaCosse, Judith
Sent: Thursday, October 20, 2011 12:44 PM
To: 'philgaylec @myway.com'
Subject: Clearwater Municipal Cemetery - Affidavit
Importance: High
Dear Mr. & Mrs. Culbertson:
Enclosed please find a copy of an affidavit granting interment rights in spaces 3 and 4 of Block 8, Lot 69 to both of you,
when the need arises, at the Clearwater Municipal cemetery. I have also attached a copy of the Clearwater cemetery
map (3 sheets).
Affidavit- Culbertso Cemetery
n.doc ip- Sheets 1, 2 & 3.F
Please review this document for any errors or omissions. If you agree with this document, have it signed and notarized by
the appropriate individuals.
You may return the completed Affidavit to my attention at your earliest convenience. We will then update our records to
reflect this information.
If you have any questions, please give me a call at 727 - 562 -4093.
Sincerely,
Judith LaCosse, Staff Asst.
City of Clearwater
112 S. Osceola Ave.
Clearwater, FL 33756
Official Records & Legislative Services Dept.
1
AFFIDAVIT
STATE OF FLORIDA)
COUNTY OF PINELLAS)
I, , the undersigned, do hereby attest that I'm the
descendant of Edna Washburn Moore, my mother, who is buried in Block 8, Lot 69,
Space 2. My mother was the owner of Block 8, Lot 69, Spaces 1 through 4, and Block
8, Lot 70, Spaces 1 and 2 in the Clearwater Municipal Cemetery. Spaces 3 and 4 are
currently vacant in Block 8, Lot 69.
Per the City of Clearwater Rules and Restrictions the maximum capacity of a
space is two burials provided at least one person is cremated or two cremated remains.
Please take this affidavit as your authority to assign interment rights in Block 8, Lot 69,
spaces 3 and 4 to myself and to my husband, Phillip Culbertson when the need arises.
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
Gayle Culbertson
Phillip Culbertson
SWORN TO and subscribed before me this day of
by Phillip and Gayle Culbertson who produced identification in the form of
and who did /did not take an oath.
Notary Public
My commission expires: