Wiersma Jr., Dirk
AFFIDAVIT
STATE OF FLORIDA
COUNTY OF PINELLAS
WE, the undersigned, do hereby attest that Dirk Wiersma, Jr., deceased, is the grandson of A.
J. and Joyce Nelson, deceased, and the nephew of Leon Perry Nelson, deceased, and has a right to be
interred in the cemetery property described as Block 7, Lot 160, Space 4, Clearwater Municipal Cemetery.
WE further attest that Dirk Wiersma, Jr. is the only child of Dirk and Flora Wiersma, deceased,
who are interred at Valhalla Memorial Park, Milwaukee, Wisconsin. WE also attest that Leon Perry
Nelson never married and has no descendants to the best of our knowledge.
WE 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 Dirk
Wiersma, Jr.
SIGNATURE
.Il1f1~ .a (.I') IIA~~.c
David Wiersma
817 A West Scott, Milwaukee, WI 53204
s~.~
113 Fairlane Court, Maquaketa, IA 52060
RELA TIONSHIP TO DECEASED
~
~-~
Dirk Wiersma
3240 Pond Ridge Dr., Newton, NC
~o.. LA.)u, ~~
Christina Wiersma
1499-1/ Elm St., Dub ue, IA D200l
~.{ ~-
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u6y\
J ness Wier a
- 55 Bluff, Dubuque, IA 52001
(\~CC ~~-~
Michele Errthum
3240 Pond Ridge Dr., Newton, NC
~
The foregoing instrument was acknowledged before me this 20th day of September 1993 by David
Wiersma, Shirley Kelly, Christina Wiersma, Jeness Wiersma, and Michele Errthum, who produced
identification in the form of a driver's license and who di.d not take an oath.
~. I IZ!Jri'()~~~
.. ....: ... Notary Public
My Commission ~,~~~: HOLLY M. AUSAN!O ally M. Ausanio
}"*';'r;~ MY COPlJ,IISSION # CG269212 EXPIRES
;%'~.~"..E April 20, 1997
"if;.,9f"f.~""'" BONDED THAU TROY FAIN INSURANCE, 1He.
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SEP-20'1<~'''\ 10: 23
CLEARWATER CITY CLER~
813 462 6488 .. 1)01/001
'ae~ll' D,.nd
Fax Transmittal Memo 7872
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OrIgin". DrDlIlIllY DAllurn OC'D"'~'"
Oi'P'I_lIOn, t..J'
AFFlDA VlT
STATE OF
COUNTY OF
I, the undersigned, do hereby attest that JJlrk Wlei'SmR. Jr., deceased, is the grandson of A, 1,
and Joyce Nelson, deceased, and the nephew of Leon Perry Nelson. deceased, and has a right to be
interred in the cemetery property described 85 Block 7, Lot 160, Space 4, Clearwater Municipal Cemetery.
I furUler attest Ulat Dirk Wiersma, Jr. Is the only child of Dirk and Flora Wiersma, deceased, who
aJ:e interred at Valhalla Memorial Park, Milwaukee, Wisconsin. I also attest that Leon Perry Nelson never
married and has no descendants to the best of our knowledge.
I further agl"ee 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 Dirk Wiersma,
Jr.
SIGNATURE
RELATIONSHIP TO DECEASED
)frP.-W~-~
Dirk Wiersma UI
3240 Pond Ridge Dr., Newton, NC
The foregoing instrument was acknowle<lge<l before me this .:J...12 day of ~, , 1993
by Dirk w)erS~~~hO is personally known to me/who produced identification' the form of a
Gl.~ .. #~~ and who did not take an oath.
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VALIiALLA
MEMORIAL PARK ASSOCIATION
5402 NORTH 91s1 6T1~EET. MILWAUKEE. WISCONSIN oaaas
TELEPHONE: AREA 414 482.3300
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