Moore, Patsy Ann RobertsAFFIDAVIT
STATE OF FLORIDA)
COUNTY OF PINELLAS)
I, Patsy Ann Roberts Moore, the undersigned, do hereby attest that 1 am the descendant
of Captain Tom Roberts, my grandfather's brother, and the original plot owner of the City of
Clearwater, Florida cemetery property described as Block 2, Lot 4 which is a forty two space lot
and currently consists of seven unused spaces, 3, 4, 20, 21, 22, 23 and 36. I am the daughter of
Claude Chestine Roberts and Pauline Courson Roberts. Claude Chestine Roberts was the son of
Claude Eugene Roberts and Mary Alice Crumpton. Claude Eugene was the brother of Captain
Tom Wesley Roberts.
1, as Captain Tom Roberts' heir, have a right to be buried in this plot. This document
assigns interment rights in Block 2, Lot 4, Space 23 to myself.
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 as stated above.
SIGNATURE ADDRESS /PHONE
G? Q 1 113 S Gt..h r se PI awe
Patsy An oberts Moore
Street Address
ear wake- EL 33765.
City /State/Zip
/2A9.9 5c /4157 -Ave L J
Thomas Wayne Roberts (/ Street Address
(Brother of Patsy Ann Roberts Moore) e. 1-/ 3.2/ 7 9'
City /State/Zip
SWORN TO and subscribed before me this 30 day of S4-�^u 2 ►S by
Pa4-G1 Ikon 2ob�+s fnovre- who produced identification in form of
i l D d w DI and who did /did not take an oath.
AP1i-30Lfti LOVE
MY CO c1Mi3SiO"i5 # E2 5 ;309
EXP :RE 3: Saptomber 9, 2016
Notary Pu • Iic
My commission expires:
SWORN TO and subscribed before me this LIT` day of a 4 by
%tomn, W , RD bee.4-5 who produced identification in th form of
and who did/did not take an oath.
—_
`" ,, JOHANNA BEEMER
Notary Public - State of Florida
My Comm. Expires Mar 1, 2015
Commission ,# EE 69308
Bonded Through National Notary Assn.
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No ry Public
- I- o?G /$
My commission expires: