Paine, Ruth Darby
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AFFIDAVIT
October 2, 1996
STATE OF FLORIDA
COUNTY OF PINELLAS
I, the undersigned, do hereby attest that I am the descendant, sole survivor and heir of JOEL
BYRON PAINE, deceased, and HENRIETTA DARBY PAINE~' deceased, who are buried in
block five (5), lot nine (9), spaces ODe and"two 'respectively, in Clearwater Cemetery. As heir to
the interest and/or control in the remaining space, space three (3~oiblock five (5), lot nine (9), I
authorize the interment ofmy aunt,Ru~Dar\Jy Paine, (daughter of Joel and Henrietta Paine) in
block five (5), lot nine (9), space three (3).
I, further agree to release, indemnity and hold the City of Clearwater harmless from liability in the
event of my claim arising from the use of the above described property for the interment of Ruth
Darby Paine.
Jersey Street
San Francisco, CA 94114
WITNESSES:
27~
PRINTED NAME & ADDRESS
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33777
Sworn to and subscribed before be this second day of October, 1996 by Cynthia Baron (niece)
who has made herself known to me by :JJr: 0a4w-L. (Identification)
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V. S. No. IA
DELAYED CERTIFICATE OF BIRTH
!
, , STATE OF IUIN~ ~
1. PLACE OF BIRTH RegIStratIon DWIGHT H. GREEN, '
Qo...Qk. () Depertment of Public .....
Countyof...._ ""-"-:-"--{':;:":;,,P D}ISt. No..... .... 2'75 S.1. ;'.1 Dlvlalon of Vlt.. StotlstlOORIGINAL
Chicago Ill' 'RoadD.... ~~, .~
....--...-............:.-...-..-..- :t:;;-1I0 Primaiy' "-11 ~treet and oh30 Llonroe Ave.
'(C&ncel th. dlree ~rmo not opplic.o I_Do nol Dist. N~..Nwnber ...'..........'....'..m........................_......_......
enter toR. R. ""R. F. D. U or other P. O. addreaa.) i"""',
2.F'U'LL NAME AT BIRTH...,....;&1..t~n.~.rp.Y..J),~1!),~......................,......, .....................'....,...
8. Sex 4. Twin, Triplet, or 5, Number In order 6. Le!;ltlmate? 7, Date of
FeIll81e other? ..------------ of blrth_h__u_ birth --~tu--b--.h--~9Dg.h-__
To b. .n.w....d onlv in the event of Iural birth.) Yps (Monrh) (Day) (Vur)
,
I
FATHER
Joel Byron hd l'lP
MOTHER
:l!enri A t t8, D'J rby
8. Full
Name
9. Residence at time
of this .birth
10. Color
14. Full Maiden
Name
15. Residence'lt time L' 70 1 .A
6b30 !..onroe Ave of this birth 00.) oO'1roe .ve
11. Age ~t tL:ne ~8 16. Color "bi tt> 17. Age <:t tif!1e ~7
of thIS birth..m.':......yn;. of thiS bIrth.m..~...m,yrs.
12. Birthplace (City or PlaCe),.....v.{!1-rr~ 18. Birthplace (City or Place)...)~QJf.'}!.f!P.0.l.L!?_...uu
(Name State, If In U. R)h____J!!1._I?!!~_____________ (Same State, If III u, R)_______Irtdtr:.P1L_________
(Kame Countn', If ForE'I"nl__.n____ __n _ _____n.. (:\ame Cnuntry, If Fore!"n) -______u_u_____________
13. Occupation 19. e>:cupation rrOu:?e~. fe
(NaturE' of Industry)_____ !c~."I"V~~________u__. .- _ (~atllr~ nf Tndu,<;tl')'l____n___ .u___Uh__n_ __u__
20. (a) Number of chil<iren bom to this mother <It the (ob) Number of children living at the time of
time of and inducting this ,birth,... ....Hu....... and including this birth...,......,..,..2.................................
21. I HEREBY CERTIFY that I was the Attendant at t~is Birth. This space only for sj;mature of
Signed...,......................._............,.,......_.........,................. ......_.......................,.........." .............................., .....".......,_"...::::~:fr:n
1ihite
Address.. ,............................,...., ......,',.....,.,.........,....,.. .._.. no. -......-m.....................,Date.." ,..." '..,...... ..,...,. .."..,. '" ..,........... ..,..,.....
o (Mandl) (Da ) Year)
IF SIGNATURE OF BIRTH ATTE..~DANT IS OBTAL""\ABLE, A.~ AFFIDAVIT IS NOT REQUIRED.
:::~ ~~::::::-...~:C:::::.::::..::.:::::.::.::::::::::::,.,J ss, This affidavit must .be made by an older ibloOO relative.
r HEREBY CEHTIFY that I ha\'eactual knowledge of the facts as stated in this record of ,birth and know
them to be true, th:lt I am related to the in<ii\'idual as.. ..~.....m'..,..'....'m..Oo...m...'m....m................Oo...._.._
and that I am at least one yearsf~~~~re_..,~~,~._.:..:0.~~....,a:{~.?.......Oo........_......_.._......__._.._,
.. ,... r L" ~ ( 0!..L-( ,1-: . . ," _ /'/ L.G..
Present Address ./...tJ...'f........__..,. c;,c-..... ..' ....m..r...~~___.._.._...._"'"_..,;,....,;L/~
SEAL Subscribed to, e::rn 1x>fore me this...$=-.,.......d:ly OL_...~....._.............. 19.'i:.~
,.........Oo...,.." ,.. .. .." ",..,..,..c,..;,..... '.. ..,... ...., ",..,......Natary Public..fl'l'................u........,Oo,Oo,...................
22. Filed...........O.C-r~..7... .m..~.. ;,~"..;;...m.......................................Oo..Registrar
Post Office Address.......::...................,..... ............,... .... ....... .._........_..................... ...Oo~,..., ...............Oo... ........... '......,.., ............'. ...._
STATE OF ILL! NOIS COUNTY OF COOK) Ss
CITY OF CHICAGO )
1. Hannan N, Bundesqn. M. D.. ReOi strar of Vital Stati stics of the City of Ch Icaqo,
do hereby certify 1hat 1 am the Keepercf tr,1Z r~cords of births.stil!blr1hs and deaths
of the City of ChlcaQo by virtue of the laws of the state of IllinOIS and lhe.
ordmc9nclZs Of the city of ChicaQo; that thtZ foreQolnQ ;sa trulZ copy 0fG rtZcord kept
by me In pursuance Of said laws .and ordinances.
"-.....- .-. '
OCT. 5, 1944
----=% ~-_._.. __ >r '::.
pre~;rdent of thtZ
by
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...''-<-----r-~ -fL_---..........
rd of Health,ReQisl,'al'
Deputy
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