Paciorek, Myrtle
CEMErERY DEED AND CONSENT TO CONVEYANrR
INST :I: ?1-203577
,JLY 3-0, 19~1 1: 23F'M
~ ' ,
, TIllS INDENfUl.E is made this ~:day of"
as Grantor and Myrtle:~k whosclmailing address' .
Pinellas, State of Florida, as Grantee:
(Signed, Sealed and Delivered
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C" -""7-
State of In~an~~" .~,~, 'r", i:L--,
County of . ~k2t*L e.. ' ....
r tI .
Personally appeared before me Mildred Marie Caldwell to me well known to be the person ,~~QI ;~~~cuted the
~foregoing instrument, and she acknowledged that she execu~~d, . d instrument as her free act and fef1.(Upr the/us~s and
!:;:purposes therein expressed. /...(1'.';.-:..:...... '
o::l ' .- '-,' ".'."1/ .. ~:r..{ ..,.',,;
~ ~ j Witnc," my hand and official seal tm.'L day of i'i~'~ I\;,".,.;~
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~ ~ The City of Cleanvalcr, Florida, a monicipal COIporatioo, hereby co"",ol, 10 the cooveyance of the .::. described
Q. tjot, plot or parcel in Clearwater Cemetery from Mildred Marie Caldwell, the Grantor, to Myrtle Paciorek, the Grantee.
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IN, WITNESS WHEREOF, this Consent to Conveyan~a: ~e: signed and sealed by the Mayor -Commissioner,
the City Manager, and the City Clerk, this.i.i.. day of -c/'O' . 19 ~
(Signed, sealed, and De"live",ed , ,,' -fu:1TY OF CLEARWATE
~'n th presence .o"Qj\U : l'~ ~ 11 RECORDING
, . 0 '\ r' ACCT Coe. L '.In (\
. (Jr;/l/j,{ ~ \. ' \, n- L...LQQffi (}By: ~
r ' ::p' ". , ",R~ ,~'~ Michael J. Wr,igQk';':
~ J Qr-r>n._~. ~FEES _______ Cou er. et!;...,~,
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(Approved as to fonn and correctness)' PTG
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PINELLA~ COUNTY FLA.
r OFF.REC.BK 7637 PG 66~
1911, between Mildred Marie Caldwell
d Way N., Pinellas Park, FL 33565 of the County of
WITNESSETH: That the said Grantor transfers ownership to Grantee and has remised, released and quit
claimed unto the said Grantee, and her heirs forever, all the right, title and interest which the said Grantor has in and
to the following described parcel of land, lying and being in Pinellas County, State of Florida, to wit: Space Three(3) if;;;L
(Third Space from the North), Lot 18, BlOCk 7, Oearwater Cemetery, as recorded in Plat Book 60, Page 30, Public
Records of Pinellas County, Florida.
This Conveyance is subject to the condition that Grantee herein shall not assign or convey said property without
the written consent of the City of Clearwater, Florida, and to the further condition that said property shall be used only
for cemetery purposes as human burial sites, and is subject to such other regulations the City of Clearwater may adopt
pertaining to use of said property.
TO HAVE AND TO HOlD the same to the only proper use, benefit, and behoof of the said Grantee and her
heirs and assigns forever.
(Grantor)
G/)-?J .LIcit /a(7J1(1 /U('u-> P,aldw.~LI
&~.
j
State of Florida,
County of Pinellas:
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Personally appeared before me Rita Garvey, Michael J. Wright, and Cynthia E. Goudeau, to,~ewell known to be
the persons who executed the foregoing instrument of conveyance in the capacity of Mayor-Commissioner, City Manager,
and City Clerk respectively, and they severally acknowledged that they executed said instriunent in their respective
capacity by and on behalf of and as the free act and deed of the City of Clearwater~FlpKt.f.Hor the uses and purposes
therein expressed. ~",';' :~;'\' ;. <
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Witness my hand and official seal at Clearwater, Florida this ..&:. :day ci.'.:'~/ -' .' .Ii,;- .
This instrument was prepared by:
M. A. Galbraith, Jr., City Attorney
City of Clearwater, P. O. Box 4748
Clearwater, Florida 34618
19 it
~. Notery PuUtC, Stale 01 Florida
~mmissioil Ell\l!rl':S April 20, WJ3
Ionded Th'Q r.oy fain . hloiun.u'~ Inc.
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June 27, 1991
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Mrs. Mildred Marie Caldwell
1609 S. 14th Street
Richmond, Indiana 47304
RE: Clearwater Municipal Cemetery, Block 7, Lot 18
Dear Mrs Caldwell:
Attached is a Cemetery Deed and Consent to Conveyance form to transfer
ownership of the above lot to Myrtle Paciorek. Please sign as the Grantor, have
it witnessed by two individuals and notarized and return the executed form to the
City. We wi 11 complete the Consent to.conv-eyance port ion of the form, have the
document recorded, and send it to Mrs. Paciorek.:please send .the deed which
indicates you own this lot back tothe',City along with the enclosed form.
If the deed you have indicates ownership to someone other than yourself,
we will need documentation, such as a will or signed affadavits from all
remaining family members, indicating you have the right to dispose of the
property.
If you have any questions, please feel free to call 813/462-6684.
c
,
~
Sincerely,
Susan Stephenson
Documents and Records Supervisor
SS/cm
Encl.
-:/-:
I,.,
",Depart_Ill of H".ilb and R"h.billt.llv,,~rvlf'l!.
- / DIVISION Of HEALTH
N -....v.. ""AI. .......,.. ,
CERTIFICATE OF DEATH
F~OlUDJ\
STATIt "I Lit NO.
DECEASED-NAME
"I"
MIDDU
LAU SEX
RI:GISTRAR'S NO,
DAn Of DEATH I MO""H, 0"", ".11
RACE _Mtfl, "'IGIO, AMI.le.... .NOIA..,
uc. t $fi'fCln I -., . J.
4, ;Jn~\,e
CITY, TOWN, ORlCX..ATlON OF DEATH
l.
Hale
J. July 9, 1974
COUNTY OF DEATH
71 Pinella&
7\ Lar 0 1r Yes
STAir OF BIRTH, II "0' '" y.>,.., ".... CITIZEN OF WHAT COUNTRY
COU...'" I
7~ 912 9th Avenue S. W.
MARRIED. NEVER MARRIED. SURVIVING SPOUSE '" W'''. G.Yf _lOON _ ,
WIDOWED. DIVORCED, "OC'N,
, US!i. _Ii 10 Hido.;ed 11.
USUAL OCCUPATION 'G'.f .'''0 O' WO" _f OUII"G ""Sf o. KIND OF BUSINESS OR INDUS11lY
WO"U"'::;' LlN. fYtN I' IU'lm I
131, Bus Drj_ver
CITY, TOWN, OR lOCATION
, Iowa
SOCl-'l. SECURITY NUMBER
It l.I78-14'":'644l
RESIDENCE - S T A 7E
140, Ylorioa
FATHER-NAME
IS,
I NfOllMANT -NAME
Hilliam
F.
14., 912-9th street S.1-1 I
COUNTY
14b, Finellas
14d,
MOTHER MAIDEN NAME
fllSf
MIDDL!
lASr
"'Sf
17., I'TS. !Iaris Caldwell
PART I. DEATH WAS CAUSED BY,
16,
MAILING AOORESS
I1b, l609-South 14th Street-Richmond, Indiana-t,73 74
:'Iargueri te
Bayless
Years
(ST.,ff 01 I.'.D. NO.. cm 01: TOWN. STATI, ZIPI
~MIDI"'Tf C"'U5t
(ENTER ONl r ONE CAUSE PER liNE FOR (oj. (b), AND (ell
(0) Occlusive Coronary Artery Disease
OUf 10, 01 ...S A CONSlQUfNCE 0':
CO,.DITIONS, If ......,. 1
WHICH GAV! liS! TO
IMMIDIAn ''''US! 101, ,
SU.lING '"f !JNDfI.
LYING 'AU Sf LAST
(b)
OUI TO, 01 "'S A CONSEQUENCE Of:
(el
DATE OF INJUR 'MO"'H, OAt, r..., HOUR
.f YES Wilt "NOINOS CONe
StOUID IN Dllt.M....,NG CAUSa.
0' DIAnt .
''',
HOW INJURY OCCURRED IINTfI ......TUII 0' INJUIY IN '..11 I O. '"IT II. rTfM 1'1
OTHER SfGNIF_ICANT CONDITIONS: CONO"'ON5 CONfI'IUTlNG TO 01'''''" aUT Nor ,',flAaD TO CAUS! GIVEN IN 'All I (01
=~~t Agil~~'gET~~:D OR
t:<'fyl
INJURY AT WORK
(SPlC'''' 'ffS 01 ~o I
7lk,
lOCA TlON
M, lGII
I SBUT 01 I.'.D. NO., CITY 01 TOWN, STAn I
lOt,
CERTIFICMION-
'HYSIC'AN,
I "'"(NDEO 'HE
711. OfCUUD ,JlOM 121b.
CERTlFICA TlON MEDICAL EXAMINER OR CORONER, 0" 'H' OASIS O. 'H'
UAMI"'AflON Of THE IODY ANo/ol THE INVESTIGATION, IN MY O"NION.
DIA'H OCCUIIED ON I'MI o...n: AN,D DUI TO TH' C"'USElS, srAnD.
no,
CERTIFIER-NAME ("'" O. ..,,,,,
lJo Roy L. Clemons, M.D.
MAllltl"....DQ~S-CE~TlF'ER R d W
lld, .lbU U.Lmer~on oa est
MONT"
OAt
YUI
...,,,'"
D.y
UA' ANt lAST ~w HaM/MfI ALlYl ON
MONTH D...Y n....
!ll<
HOUI Of Df~ TH
I DIOlolO NOT VlfW fHf DEATH OCCU..EO AT IN' 'lAC., ON ,"I
100' .n" Of A,". C HOUII DA", AHO, TO '"' II"
0' MY ItNOWLEDGI, D"'"
lid. 211. M, TO ,"I CAuSlfSI 5T","0.
TO
lOb, Largo Cemetery Largo
FUNERAL HOME-NAME ANI> ADDRESS_ ! $TI~T 01 ..f.D. ...~.. CITY 01 'q.",.,.. S'4',_ ZIP I
So Moslil FuneraL Ho)l(e - 8u2 Nortn, Ft. tiarr1S0n,
REGIST IGN4WI:f ~
3:45 P.
YEAI
""y.
CEMETERY OR CREMATORY-NAME
Cll''' 01 fOWN
5T"'"
Florida
JJSa5
Clearwater. Flori a
A CERTIFIED COpy MUST CARRY THE EMBOSSED SEAL OF THE REGISTRAR OF VITAL STATISTICS
I hereby certify that this is ~ true and correct copy of a certificate
on. file in the office of the Lucal Registrar of Vital Statistics of the
Pinellas County Health Departmp-nt. St. Petersburg, Florida"
~{As;:;;.~, Deputy Local RegiHrar
.JUl
1 7 1974
irt
't'i.. '
STATE BOARO OF HEAL~
BUREAU OF VITAL&TATIS1'ICS
CERTIFICATE OF DEATH
FLORIDA
STATE FILE. NO.__
REGISTRAR'S NO.
Pi 1 as
b. CITY. TOWN. OR LOCHION
2. U50UAl. n[510ENCE ( Jr"",(I' dtClQjtd ""..i 1.' iruhluhll''': R14t41,..(. b,,{/We ad.."ui.,,,)
a, STATE b, COUNTY
ernTH NO.
I. PLACE Of' DEATH
o. COUNTY
Lar~o
d, NAME OF (If not ill ho'pilal. girt ,I,ul add",,)
tiOSP,TAL OR
INSTITUTION Suncoast Osteonathic HOsDita1
3. NAME Of'
DECEASED
(Tvp< a' p,int)
Clearwa.ter
d. STREET ADDRESS
.Pt.n e 113. Z
<. IS RESIDfNCE
INSICE CITY UMI IS'
YES~ NOD
Florida
c. CITY: TOWN. OR LOCA nON
1495 - South Creenwood Avenue
Firtl
.\fiJd/<
LOll
Month
Dnv ~"a'
F ema 1 e
'4. DATE
OF
Lelia Eunice Storbeck DEATH December
6 co..OR OR RACE 7 MARRIED ~ NEVER MARRIED 0 8, DATE OF BIRTH 9, AGE (fn.v'Otl
Ia..~ b9i,lhdOV)
WIOOWEOO DIVORCEO Ju1v 2w 1918 4
lOll, KINO OF BUSINESSOR INDUSTRY II. BIRTHPLACE (SltIl' 0' fa't1~n counl,v)
\.fni te
.\1 i... ,
5, SEX
lZ
lOa. USUAL OCCUPATION :Gif' killoJ o/.fo,k don,
dflrino mOJt 01 u,,",t4:il1V' lljt, trtn if rttirtd)
Romer.'". k~r
13. FATHER.S NAME
Ol-m Home
Dunne110n
Florida
U.S.A.
14. MOTHER.S MAIDEN NAME
Robinson Irene (unkno~m)
16, SOCIAL SECURITY NO, 17 ,lNFORMANn S1CNAT/~ / #' Add,w 1495 - South~ Gre~mrood
258-20-3832 0(..h..~c/. W.h-k."..c.... C1eaM/ater Flonda
18 C:AUliE Of DotATH [enltr on/v ,on' ca,,,,, p<'/ln~<,!:rza,,)' 'l>,),~ndl~CI,1 ,'~, /), " ,", '
PART I. ,DEATH WAS CAUSED BY, --;;// ... j.("', . y
IMMEDIATE CAUSE (0) -/~ 1j.;,{",.L.az- .', _ +- - LL -,
. , ' ,/--c:::; .}; , . " ! ) ,
;~i~~I;a~~' ~,~nr~ I DUE 10 (~~..:/~Lld'(.,f~" , ", :,.. ?~--4:P'cD:22.cfZ->, ",---'~
ahort ('till." (al. '-
.J14/ing '^-t II 'ldo.. .
IViug (II'''' la,/. DUE TO ((1 -/.- .. ". "
PART II, OTNER SIGNIFICANT CONOlml,iS CONTR.BUTlNG DEAlH 8111' NOT RELAITD TO THE ITR"'NAL DISF.ASE CONDITION GIVEN IN PART I(il)
A.venu e
. WAS AUTOPSY
PERFORMED'
YES 0 NO (;g
ZOa, Il'rob.bl1)
ACCIDENT
o
SUICIDE
o
ZOC TIME OF /lou, ,\fo"lh, [)av. ~"a'
INJURY a. m,
p. m.
.Od, lNJURY OCCURRED
:~~L: AT 0 ~~~~~~E 0
CITY. TOWN, OR LOCATION
COUNTY
STATE
o1nd hut 3.~ :,% alive on
Z3J, LOCATION (eiIV.lown. 0' co""IVI
Pine11as Countv
Z6, REGISTRAR"S SIGNATURE
g~~ cE.
I hereby certify that this is a true and correct copy of a certificate
on file in the Office of the Local Registrar of Vital Statistics of the
Pinellas County Health Department, St. :e~rsburg, Florida.
July 10, 1968 ~<-'4t- 6 ~4::!..Deputy Local Registrar
....:
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V''''
2~ J~)
; .J. ~~wuj ~dut1~..
.w-M ~ iN-M/~4~~
. Jud:k e.QA~ . H.i<v ~ Uv """'- '-flu...
, (Yd-. e .b'vrn.. ~~ ~'<1iL ~ /Cfb 7 Iu.... ~
~ -to -;Ur- ~ J.o.J <1<-'-<<- -(; ~,~.fl.. \
,M,~ de.
.J..- tLtrL d ~ ~ cr- ~ ~ ~
~ndli-6rtd/~~~'
J~ !t'*'-
n ~ ea/d!wd/
7/12/91
Dear Mrs. Caldwell,
We have concluded the transfer of cemetery property and are returning
your original documents to you.
Si,~ erely y m t\'i,-f, 'D
/y(~ t' I L 0 L.-,PJ..-l.,'\
Camille Hotley ~
City Clerk Department "
RECEIVED
JUl 1 1 1991
CITY CLERK
..;'
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"'.~.,:3
CITY
OF
CLEARWATER
POST OFFICE BOX 4748
C L,E A R W ATE R, F LOR IDA 346 1 8 - 4 748
July 11, 1991
Cynthia Goudeau, City Clerk
City of Clearwater Municipal Cemetery
P. O. Box 4748
Clearwater, FL 34618
Dear Mrs. Goudeau;
Please take this letter as your authority to grant Right of Interment in the
following property at Clearwater Municipal Cemetery:
Space:
Lot No.:
also granted to place a memorial on the
Space One ~ (North most space). '
\
50 ""\
'"
site.
Permission is
Block:
8
For:
Richard Wa 11 er
Very truly yours, ~,~
Paciorek
(Lot owner)
o
.. E qua I E m pi 0 ym e n t and A f fir mat i v e Act i on E m p I oyer ..
.. ~ .., .
-..'
C I T Y
OF
CLEARWATER
POST OFFICE BOX 4748
C LEA R W ATE R, F LOR I D A 3 4 6 1 8 - 4 7 4 8
July 11, 1991
Cynthia Goudeau, City Clerk
City of Clearwater Municipal Cemetery
P. O. Box 4748
Clearwater, FL 34618
Dear Mrs. Goudeau;
Please take this letter as your authority to grant Right of Interment in the
following property at Clearwater Municipal Cemetery:
Permission is also granted to place a memorial on the site.
Block:
Space Three (1) (Third space from the North)
18
7
Space:
Lot No.:
For:
Henry F. paciorek
Very tru ly yours, ,'~ ~)
:JY\~ \?c--c,~
(Lot ~ner) Myrtle Paciorek
(Lot owner)
o
, , E qua I E m ploy men tan d A f fir mat i ve A c t,i 0 n E m p I 0 Y e r ' ,
!.
-:i'!
August 13, 1991
Ms. Myrtle Paciorek
7822 72nd Way North
Pinellas Park, FL 34665
Dear Ms....,._:
Enclosed is the deed and consent to conveyance which indicates
that you own Space 3~ Lot 18, Block 7, in the Clearwater Cemetery.
This deed has been recorded in Official Records Book 7637, Page 662.
It is important to keep this deed in a safe place and to make
a separate note of the official record book and page numbers. In
the event the original deed is lost or destroyed, this information
will be needed to obtain a copy from the Pinellas County Clerk of
the Circuit Court.
If we may be of service in the future, please call upon us.
Yours very truly,
Susan Stephenson,
Documents & Records Supervisor
SS:em
Ene.
)(~~~
AFFIDAVIT
STATE OF FLORIDA)
COUNTY OF PINELLAS)
I, Myrtle Paciorek, the undersigned, owner of cemetery property described as Block 8, Lot 50,
Spaces 1, 2, 3 and 4 do hereby grant right of interment to my son, Richard Waller, in Space 4 upon
his death. Space 1 is vacant for future interment of myself. James Waller is buried in Space 2 and Max
Waller is buried in Space 3.
Please take this affidavit as authority to also grant interment rights for my daughter, Nora
Scarbrough, in Block 8, Lot 50, Space 4 in the Clearwater Municipal Cemetery upon her death.
We understand that the maximum capacity of a space is two burials provided at least one person is
cremated.
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 rights
request made.
SIGNATURE : Myrtle Paciorek (Owner)
(Address) 7770 Starkey Rd., Apt. 108-D, Seminole, FL 33777
SIGNATURE : Witness
Relationship to Witness
(Address)
SWORN TO and subscribed before me this day of , 200, by
personally known to me or has made herself
known to me by
(SEAL)
(identification).
Notary
My commission expires:
Dated: