Coulston, Donald
January 20, 1994
A FFID A VIT
STATE OF FLORIDA)
COUNTY OF PINELLAS )
I, the undersigned, do hereby attest that I am the decendant, sole survivor and heir of Omay F.
Blanton, deceased, who is buried in Block 8, Lot 57, Space 4, in the Clearwater Municipal Cemetery.
I am heir to all real property, including cemetery property. (see copy of will attached) Please take this
affidavit as your authority to inter the cremated remains of Donald Coulston, deceased, my husband, in
Space 3, Lot 57, Block 8 in which my father, Grover C. Blanton is interred.
I, the undersigned, wish to inform the City of Clearwater Municipal Cemetery to place my
cremated remains in space 4, Lot 57, Block 8 with my mother, Omay F. Blanton upon my death.
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 either interment.
SIGNATURE
'~~J~ (? ~n
Doris Coulston
105 N. Lake Drive, Clearwater, FL 34615
WITNESSES:
SIGNATURES
Wertvu ~ j de jJ~
UJoann F. Dunlap
3937 14th Ave. S. E., Largo, FL 34641
LD~ }y\n\()~~
Camille Motley
1140 ldlewild Drive S., Dunedin, Fl 3 8
RELATIONSHIP TO DECEASED
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re furegoinjl instrument was ~CIrnOWledged before me thisda- ~ay of fk.,.H1 . fAd-- ,
, ort'S (I0f.,(L-S-C On {-JOa/711 L{n ~ who produced identificati~
rL4h-,ilers Llc..EAJ-s€," and who did/did not take an oath.
199j, by
form of
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ary Publ~C~~'''''X~f~:._, . HOllY M. AUSA/JIO
~:.J~t}~J. W COI.t\~:~!GII.I,' CCZG9212 EXPIRES
'~;;;S~i:.~;' . ',pril' 21J.1997
. . I""", :'. .,0 ~ O"''Jro..... -.......::; T~O'{ F.~m !:JSURANCE, INC,
My commISSIOn expIres: .
(SEAL)
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105 LAKE DR.- CLEARWATER. FLORIDA 34615
2Oll. PLACE OF DISPOSITION (HelM oI~, ~.""'l' or 2Oc:. LOCATION - Clly 01 Town, Sial.
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southeastern Cremator Clearwater, Florida
21b. LICENSE NUMBER 21C. NAME AND ADDRESS OF FACILITY
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National Cremation society ~~
4945 E. Sa Dr.- Clearwater Florida. 346m
cr.. 23... On tM _ ol......in.toon .ndIOI,......ovabon, III my 0Il'1llOl'l delln OCQlIfed II ~
~ - 1M lime, daI. end plac. end due 10 t/le cauH(,land man_ u ~. "
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e2~;MEDIC1\LEXAMINER CASE NUMBER ~l
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7747#31
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FEB 9
JM THE CIRCUIT COURT FOR PINELLAS COUNTY, FLO
12. 14 PM . ~ f . ',R f COR 0 E b
PROBATE DIVISION NO. 87-660-3E . ~..
iEB041987
IN RE:
THE ESTATE OF
Deceased.
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COU~6N, ~S~
OMAY F. BLANTON,
01 C<1!.:'1 .: '. 0 ORDER OF SUMMARY l\DMINISTRATION
40 RccqJ?---- (testate)
41 OS -'----
43 Int - -
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Tot-f-V_v_~~ On the Petition of DON COULSTON and DORIS
wife, for Summary Administration of the Estate of OMAY F.
BLANTON, deceased, the Court finding that the decedent died on
the 24th day of October, 1985, that all interested persons have
been served proper notice of this Hearing, or have waived notice
thereof; that the material allegations of the Petition are true;
that the Will bearing date of June 17, 1970, has been admitted to
Probate by Order of this Court as and for the Last Will of the
decedent; and that an Order of Summary Administration should be
14 lQS7tf1G2"12
'19
,~ TOTAL: :~.
ADJUDGED, that there be immediate distribution of the
entered, it is
1 . O~FF
1.99
9.09 Cf-:
assets of the decedent as follows:
DON COULSTON and DORIS COULSTON, his wife, 105 Lake
Drive North, Clearwater, Florida, 33515, are entitled to and
shall receive decedent's entire one-third
(1/3)
undivided
interest in the unpaid balance of that certain Mortgage and Note
recorded in OR Book 4788, Page 554, public Records of Pinellas
County,
Florida,
dated
12 December
1978,
whereby JUDGE
..- . -. ".
CONSTRUCTION, INC., is the Hortgagor and Ol-1AY F. BLAN'l'ON, DON
COULSTON and DORIS COULSTON are Mortgagees, which one-third (1/3)
interest approximated $12,524.68 plus interest as of the date of
her demise.
ADJUDGED FURTHER, that those to whom specified parts of
the decedent's estate are assigned by this Order shall be
RETURN TO:
C. tv .1,/t.)GILxIJ/fYf-'//
.sor $. ,7,. ~!' lOt ,,:-)/1 ::.~ I -1-
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receive and collect the
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