Ponds, Gary
10- 8-02;~2:10PM;CITY CLERK DEPT.
; 727 .562 4086
# 2/ 2
October 8, 2002
AFFIDAVIT
I, Betty Campbell, am the owner of Block 15. Lot 116, Space 2 (a/k/ a Space C) in
the Clearwater Municipal Cemetery.
Please take this affidavit as your authority to grant interment rights to Ga1;y Ponds in
Block 15, Lot 116, Space 2.
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 above described property for
the interment of Ga1;y Ponds.
SIGNATURE/RELATIONSHIP TO MR. PONDS
ADDRESS/PHONE
15JJU~!/:
.,
fJ. ~ORE ME, the undersigned, personally appeared Betty Campbell on
(YQ j >12/) , 2002, who executed the foregoing inst:rwnent and acknowledged the
execution thereof to her free act and deed for the use and purposes herein set forth, and
I . . -'" Ij
who has produced a~means of identification or is
personally known to me.
N atary Signature
"~iifl"~ Dottie Reehllng
{.'1 \~ MY COMMISSION # CC849381 EXPIRES
~\ .~~ff September 30, 2003
"1,:r..9f.,f.;~", BONDED THRU TROY FAIN INSURANC~ INC
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City of Clearwater
OFFICIAL RECORDS & LEGISLATIVE SERVICES
TO:
Bob, Reese Funeral Home
FROM:
Susan Stephenson (727/562-4097)
RE:
Gary Ponds
DATE:
October 8, 2002
I am sending the Affidavit granting interment rights to Gary Ponds in
the cemetery space owned by Betty Campbell located in the Clearwater
Municipal Cemetery. Please instruct Ms. Campbell to sign the affidavit in the
presence of a notary. Please have her return the Affidavit with original
signatures to us prior to the need for the space. The affidavit should be
mailed to:
Susan Stephenson, Document & Records Supervisor
Official Records & Legislative Services
City of Clearwater
P. O. Box 4748
Clearwater, FL 33758-4748
If there are any questions please feel free to call me.
Total pages faxed including this page - 2