Sims, Cora
01/11/2005 11:02
7275522023
DISPATCH OFFICE
PAGE 1212/02
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3:...;"i~02'i 3:S5PM;CITY CLEJ:lK D~PT.
; 727 562 4088
11 2./ 2
March 11, 2002
AFFIDAVIT
Cop~
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I, Dorothy M Varderau. is the daughter of Arthur F Chancey who is the owner of
Block 9, Lot 54, Space 21n 1he Clearwater Municipal Cemetery.
Please take this affidavit as your authority to inter the remains of CORA SIMS
whois the widow of Arthur F Chancey, in Blocl< 9, Lot 54. Space 2.
I, further agree to release. indemnify and hold the City of Clearwater hannless
from liability in the event of any claim arising from the use of the above described
properly for the interment of CORA srMS.
SIGNAlUREI
YJ. . . LATIONSHIP TO DECEASED
~~LkJ~
, orothy M Von u .
ADDRESS/PHONE
~t:~E:~:aokr.br
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and ~ub$cribed before me this /3 day of March, 2002, by
d ~ tJ who is personally known to me.
turel(Prlnted name}
!'~~~ JAMES J. KlJIUSCH
h "Q.~ MY COMMISSION it CC 835514
~~ eXPIAES: September 5,2003
~ij'f..::<O. 60ndDd Thru No~ PIlIll/c Undenornars
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