Stoll V, William
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AFFIDAVIT
STATE OF FLORIDA)
COUNTY OF PINELLAS)
I, the undersigned, Delia Mendez, owner of Space 4, Lot 108, Block 15, do hereby
Grant Right of Interment to:
William Stoll V, in Space 4, Lot 108, Block 15 ill Clearwater Municipal
Cemetery .
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 William Stoll V.
SIGNATURE
~ 'm"~
Delia Mendez
RELATIONSHIP
(Address)
I ;} ~~<: ~:5-/ cyf/4'C!.
Witness
(Address)
~~F}~337SG
Witness
(Address)
The foregoing instrument was acknowledged before me this My of
by Delia Mendez, who produced identification in the form of I ~3 v
and who did/did not take an oath.
,2001,
'-2/~ 76?-O
i~IiiWf~ Dottie Reehling
~: :*~ MY COMMISSION # CC849381 EXPIRES
~'" *,"... September 30/ 2003
"'~ilii~~' RONtl!tl TH~tJ T~I")Y FA1N INStJRANce; INC.