Vanderau, Dorothy
~1/11/2005 10:11
7275522023
DISPATCH OFFICE
PAGE 02/02
..J
.--
',... --.. ~ 'S'':''i3~oE ',' 2'; '34 PM ie',' iy' CLiR'K" DE.pi:........."...,.....". ---.. -- -.........,..,...... --.--..."; '7'ii' '562 '4.086..""....".. -- #... 21' -- .2"......
March 14. .2002
AFFIDAVIT
I. Dorothy Vanderau. daughter, do hereby attest that I am the
surviving heir of Arthur F Chancey. deceased, who is the owner of Lot 54,
Block 9. Spaces 1 through 4 in the Clearwater Municipal Cemetery.
Please take this affidavit as authority to grant interment rights for
Dorothy Vanderau in Space 3.
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 the above descendants.
i
SIGNA TUREI
RELA TrONSHIP TO DEC~ASED
y/Jz~!:.!1:0c1-~~ -
ADDRESS/PHONE
.pJ2 iJ:ir_~ 'Dr.
~PA...... (1"
3 755
SWORN Tg af}d supscribed before me this __day of March. 2002
o PT- VlfJfUd~f"i who is personally known to me.
r
ature (Printed Name)
~":'~;!J;~... JAMES J. KLAUSCH
t{. ~ .~~ IAV COMMISSION II CC9355. 14
"~:-o/ EXPIRES: SGprembe~ ~, !WJ E.
--''.;ifr;.r..~' EIandodThIU Nol.1lY PullIlc UOd9rw/t1918 f7
[
~ ......
; .,~.~., ,...