Baeckler, William WorlineAFFIDAVIT
STATE OF FLORIDA)
COUNTY OF PINELLAS)
I, William Worline Baeckler , the undersigned, do hereby attest that I am
the descendant of Nellie Grace (Black) Worline , my grandmother, owner of
Spaces 1-4 of Block 4, Lot B in the Clearwater Municipal Cemetery. My grandmother is
buried in Space 2 (full burial), Ruth Baechler (my mother) is buried in Space 3 (full
burial) with Karlos Baechler (urn burial). Spaces 1 & 4 are vacant.
Please take this affidavit as your authority to note the right to property described
above to myself. Per the City of Clearwater Rules and Restrictions the maximum
capacity of a space is two burials provided at least one person is cremated or two
cremated remains.
I 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
William Worline Baeckler
1-7 > r-t ed. 'L,_. ty
w/ 321 -3 `C33
SWORN TO and subscribed before me this day of
IS- by L); t ■0' CA-3 . �C�k�Y' who produced identification in t e form
of iA and who did /did not take an oath.
Notary Public
My commission expires:
i
Status of Block: 4 Lot: B as of 08/13/2015
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED PERMIT
2 FULL WORLINE NELLIE G 6/26/1888 05 / 01 / 1930 1/1/1901 0
3 FULL BAECHLER RUTH 4/23/1910 01 / 28 / 1971 2/1/1971 819
3 URN BAECHLER KARLOS 1/1/1982 08 / 24 / 1982 8/24/1982 1479
DISINTERMENTS FROM SPACE:
No Matching Records
REINTERMENTS:
No Matching Records
Page 1 of 1
? QU '
Records for Clearwater Municipal Cemetery; office 122 S. Osceola, 2"d flr.; Judith LaCosse. Hrs: 8 -430p
RE: bk: 4 Lot B, space 2; owner Nellie Grace Black Worline (my grandmother) b. 6/28/1888 —d. 5/1/1930
Space 3 is Ruth Worline Henrietta Baechler (my mother) b. 4/23/1910 - -- d. 1/28/1971
Space 3 is also an Urn: Karlos Hartman Baechler (my step- father) d. in 1979; ashes placed in 1982
Spaces 1 and 4 are vacant.
My name is WILLIAM WORLINE BAECKLER b. 7/9/1937.
When I die, arrangement is for Farley Funeral Home, Venice, FL will cremate remains and place ashes here.
I would like permission to buy and place a marker on this block with our names on it.
My address is 4750 Egret Road, Venice, FL 34293; phone @ 941 - 321 -3833. Email: suncoast43 @comcast.net
Bruce Grafton Carroll?
b: Abt. 1899 in MEMPHIS TN?
William Worline Baeckler
b: 09 Jul 1937 in St. Petersburg, FL
m: 09 Apr 1971 in Princeton NJ
Ancestors of William Worline Baeckler
Johnann Michael Werlein
b: in Germany
Michael J. Worline
b: 1738 in Germany
d: 01 Nov 1804 in Northhampton, Penns Twp, PA
Henry Worline
b: 28 Jun 1785 in Pennsylvania
m: 10 Dec 1810 in Pickeway Co. OH
d: 30 Sep 1824 in Richland Co., Marion, OH
Henry Worline
b: 04 Jan 1825 in Delaware County, Marion OH
m: 19 Sep 1847 in Delaware OH
'd: 26 May 1905 in Prospect OH
Catharine Schatz
b: in Germany
�-�;1C cam; ! -
Henry Carey Worline
b: 20 Feb 1863 in Galena, Delaware Co., OH
m: 10 Mar 1886 in Galena, DelaWare Co. OH
d: 28 Mar 1900
Catherine Cline
b: 13 Dec 1790 in Kentucky
d: 07 Jan 1858 in OH
Henry Watt Worline
b: 01 Jan 1888 in Dell Rapids, Minnehaha, SD
m: 06 Aug 1908 in Marion, OH
d: 16 Jul 1980 in San Antonio TX
Eunice Main
b: 19 Feb 1825 in Horseshoe Delaware, OH?
d: 17 Sep 1917 in Village of Prospect, OH
Willi*un U. Curtiss
b: 1819 in Canada
Ruth Worline
b: 23 Apr 1910 in Marion OH
d: 28 Jan 1971 in Tampa FL
1
Alta Bell Curtiss
b•11 Jan 1861inIL
d: 10 Apr 1953 in Marion Co. home, OH
Jane
b: 1831 in Canada
John Black
b: 1838 in Oxford (Johnson Co.) Iowa
m: 1875
Nellie Grace Black
b: 26 Jun 1888 in Queen City, Schyler Co. Mo
d: 01 May 1930 in Miami FL
John Luce
Sarah Amanda Luce
b: 09 Mar 1848 in Butler Co., PA
d: 23 Jul 1939 in Queen City MOI
Mary
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STATE OF FLORIDA
T1' y 1 1 I.tS 1 �. T1 :�
OFFICE of VITAL STATISTICS
CERTIFIED COPY
CERTIFICATE OF DEATH
Depefftwesa ! OF HEAL ��
- FLORIDA
ammo wwwsANAMmcs
BTTATE "MA NO.
RCGISTRAR•3 NO.
1-00366a
00348
—HAW Pte, MIROIR EAST
1. Ruth Baechler
Sfll ,DATE Of DEATH 1 MONTH, DAT, TEAR 1
IZ Female (� Jaruary 2P,, 1971
L
RACE wfMTE, NEGRO, AMU CAM INDIAN,
ETC. I SPECST >
4 White
t AGE —LAs, 1 TEAR I UNDER I DAT
DATE OF BIRTH 1 �ONTM, D. COUNTY OF DEATH
"EAR
5. Apr l 2.1, _S =-J ;TIT H_ l l sbcrou�h
M4STITUTION —NAME a 11 NOT m IONE*, Gni STTIEET AND NuMREt 1
Gener-' ? os, t.l
1,uNDEI
I MONDAY HEARS I THOS. I OUTS
�n Asa
I M1s1DE Cm IMAM
STECIET TES OR NO 1
JTa Yes
1 HOURS rM.
sE. <
HOSPITAL OR OTHER
a. Tama
CRY. TOWN. OR LOCATION OF DEATH
W Tampa
STATE OF BIRTH I n No? IN u. S.A., **maICOTlZFN OF WHAT COUNTRY
Cot, —,•,,I
Ohio IR t'. S.:;.
MARRIED, NEVER MARRIf.D. ;SURVINRVG SPOUSE 1,r winn. c1TE MARTEN NAME I
WIDOWED. DIVORCED ISncln
1o. °tarry. ^d :Il ' Sri os Baech-:ler
AL SECURITY !MEMBER
261 -22 -4315
USUAL OCOJPA! OPL I o.ie RIND Of WOR DONE JURING MOST Of I I MMO Of BUSR,eSS OR IPQUSTRY
WORKING LIR, EVEN If RETIRED I
ia. Fouse ?. -ife !IA
RESIDENCE —STAic
1N. Floridat
COVITY
1•.., :11st'or..ug
cm LA+1. !STREET AND NUMBER
CITY, TOWN, Ott LO ...soft ...soft 1TON ■ sPECO• TES CM NO .1
14. 1.am'a :TEE `'FC ,Iw '' -a et Flora
FATHER —NAME FIRST MIDDLE LAST
.T n
o _re
MOTHER— MA1DEN NAME NRST MIDOEE LAST
u ( T ,� - T „ 1
.
INFORMANT —NAME IMARING ADDRESS eSRREET 0E 4 f D NO., CITY OR TOP., STATE, I1,1
Karics Baecl - ; er I 1O1_ =�st F1-c- -; -:-,- :, Florida
va [In
PART I. DEATH WAS CAUSED BY ENTER ONLY ONE CAUSE PER LINE FOR (oi. fbi, AND (cij
••• I
wPERORIMAIE HOME.
RETWREN ONSET AND DRAM
11. IMMEOUtt uusE •
C ON DITipM„ IF AMT,
WMICN GAVE RISE TO
IMMEDIATE CAUSE tat,
STALING THE UNDER-
LYING CAUSE LAST
I)47f 70, OE wi ftSEGV .C1'61:1.
CE O
(b) m�- ' 11'7,-e- C . '-f" �� ./".
% -e j�
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DUE TO, OR CO E Oi:
y�1
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PART 1I. OTHER SIGNIF ONDTmONS: CON s conk . ING To M E t RELARD TC, ._•SSE CGy.,,pppKKE ART ■ I AUTOPSY
/ ii�T. OE
�__J� S �1L
IF YES WERE FINDINGS CON-
• SI DEEED IN Dt1EWINING GUY
• OF DEATH
I ACCIDENT, SUICIDE OR DATE OF MJURY mow., DAT, TEAR 1 (HOUR
• OR UNDETERMINED f/ ■
IMb. j la.
AT WORK PLACE Of INJURY .T IIO.IR, /ARM, STREET, FACTOR.. t LOCATION
TES W NO I
I oEFM3 SLDG., ETC. 1 SPECIFY 1 !
311.
( HOW INJURY OCCURRED I ENTRE NATURE OF IKiUrr M PART I ON PART 11, ITIW TO I
A4.1 21M.
STREET OR E.fD. NC.., CITY OR TOWI, STATE
CBMFICAT)ON— MONIN D.T YEAR /E AND LAST SAN NM /THEE ALM ON I 010 /DID NOT TIER INE, DEATH CCCURRED AT ME 't14, ON ME
►MYSKIAH: TO AWf DAT TEAR I RODT Vi}RA1AM. Np DATE, AND, 10 DM REST
1 ATfASED THE I2 J I� )2# A TO MT CAUSEIEOGE, DUE
if< DECEASED fROM T1Y ITIt �.' L%•" i / < /// / 2 M. TO ME CAUSE 151 STATED.
CURT ICADON—MEDICAL EAAMiN*R OR CORONER. ON ME us.s 0i ma
E RAMMATION Of I11E BOOT AM/ OR 1M WTESTIGATION, DT MT DEINIOn,
DEATH OC3'WIED ON THE DATE AND DUE TO *ME CAUSE ISI STATED
13.
CERTIR
HALING
J7d
SURIAL. CREMATION, REMOVAL
! SPECIFY I
Rem. & Burial
DATE .,OWN DAY, YEAR)
F. 1).1,1971
moult 01 DEATH : tME DEC NT WAS PRONOUNCED DEAD
1 M01A14 DAT TEAR
1x..71
M.i Ti'R ..c."L2rV • ..
SIGNA:
ZJi
MOOR
*,E -DATE
50
OR TOWN
_. Florida
`CEMETERY Of CREMATORY —NAME ,LOCATION
CITY OR TOWN
x► Cemet er•., 1241 �ia .,�, Florida
FI;NEW1HOhLE— AND ADDIRESS; , &j.5E;ORp :.D. NC. C:TT OR 10 N, STATE, II
zs.
son ^^cr. .o., �r`e _ ave.J �a"I'a
2. CL . �LSLGNA TTURE
/ 1fA41.f'..f/
STATS
Fla. 33603
/1 /97/
aG�
T� , State Registrar
Date Issued: FEB 0 6 2009
THE ABOVE SIGNATURE CERTIFIES THAT THIS IS A TRUE AND CORRECT COPY OF THE OFFICIAL RECORD ON FILE IN THIS OFFICE.
THIS DOCUMENT IS PRINTED OR PHOTOCOPIED ON SECURITY PAPER WITH A WATERMARK OF THE GREAT
WARNING: SEAL OF THE STATE OF FLORIDA ON THE FRONT, AND THE BACK CONTAINS SPECIAL LINES WITH TEXT
AND SEALS IN THERMOCHROMIC INK.
DH FORM 1946 (08 -04)
25228528
1, CERTIFICATION OF VITAL RECORD
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Predate
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Mr tome. arrl
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OFFICE of VITAL STATISTICS
CERTIFIED COPY
11�1llrii► �li�s=" +0�`i111ii11TIr
BUREAU Of VITAL STATISTICS
tAom'=
t*RTIFICATE OF DEATH
Mae* ?Se N.
rr.ci et N.
City er Town N.. •r- -�• NMiatorod N. •
-614/11...6;Altet.... N,... 7,.•e -- 1M .- 444,e. �� �
v'-
.a. SL, Ward
tH 4..Is a a si1N or lea , save no 1tAMR betook d tweet out suatler)
Lase* of ',otdecaee to y ''ur town where de occurred yre.!_L/.mae..e._de. How loos is U. S. U of fereISa MrtiT..__yn._._.mw.____ds.
2. PULL NAME` CtatieL _ _ •
(a) Residence: \... /bat — Qlit A.t'. ...- .., WaM
11'.«.1 rh.. .I..4) (if uasal/.M. {fit •lfy nr ••.awn and Su.rl
MEDICAL. CERTIFICATE OF DEATH
PLRSOWAL AND
STATISTICAL PARTICULAR_
•
1 t. COLOR OR RACY. 1. Si . isarried. widowed
1 ..d (D o word,
4U-if?
11 LESS thaw
1 tllgr,_ _M.
er_
81. DATE OF DEATH Omagh. 4.y. atsi Pier) / • 195.4
22. 1 HERESY CERTTTY. That 1 attaadod deceased from.___.____
cc 4. 1a34_, to. __gee-AlaL__1 lo3a
1 leaf raw It.!_Y.alive oa 144-0--v . 1923A. death ht said
o acre occurred on t)to date stated above,
T1. prlee4el cameo of sheds and related
of rood were as fdiowe t
it
Importance in order
S. iltai.. prwlusoton. or M
Mad of work dome, as qi
ednp•sr. Marstt_ar. eta.
�. tMaatss or bsafaees la which
work was dose. as sit WE.
some. kaak. ate.
10. Data ieesa,u4 last worked at 11. Total time (years)
ehIa oeaepatisa Meath sod .pest
year) `e -- oeeopatloa
a
15. B1RTSPLACS lofts r teas► yi.. ..
(State er cOaetry)
15. MAID
LACE (clts or Iowa) .
or Mastry)
)Ill Nw1fE//
16. BIRTHPLACE (nits or tone)_. ..-
(data or ewestry)
17 TNIOS1iAN..-
(Addres:..ryt —Yta a
B MAT .O OVA
1p P1tiNM- i�KM/JIA• -• ^�Ct.� Date
caabAtrary room of Iw.partan,. not related to Drincipal
naa0a:p
Name of operation.
What toot ooaares.d diagnosis
1
Date of
�ea «Was there as ■utop.y
Ii. If death war due to external causer (viebae +) fi1l in also tit.. fol-
itlw lag t
Accident, suicide. or homicide? ._ Data of injury . 15._..
When did injury occur!...
ler«uy My or two. rordt. end Nntr■
Specify whether Injury occurred in hdmetry, lw hone, or in public Once.
efaa.er of Injury
Piatuie of Injury
l:t. Was dice.* r iajnry In any way related to ocwpstfon of deceased T_O
If so. specify ��
(►awedi._� %�/_ eirefefr4__/�__/! cl! /S.Ss!W... M.D.
(Aiinor).b4401 t4L4116-c"1 . -. -- 4214 •
2t. PILED_
•
, State Registrar
THE ABOVE SIGNATURE CERTIFIES THAT THIS IS A TRUE AND CORRECT COPY OF THE OFFICIAL RECORD ON FILE IN THIS OFFICE.
THIS DOCUMENT IS PRINTED OR PHOTOCOPIED ON SECURITY PAPER WITH A WATERMARK OF THE GREAT
SEAL OF THE STATE OF FLORIDA ON THE FRONT, AND THE BACK CONTAINS SPECIAL LINES WITH TEXT
AND SEALS IN THERMOCHROMIC INK.
WARNING:
2009
DH FORM 1946 (08 -04)
25470930
CERTIFICATION OF VITAL RECORD
11
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11
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State Board of Health
Bureau of Vital Statistics
CERTIFICATE OF BIRTH stst.t ri` x'
FLORIDA ltegfitns's '.'sue 3 _
1. PLACIt O, siaTH:
(.1 caa.a Pinellsa
moues. 3901
(b) Prsrt..t Pr.ehat 20.
(Wrier rata; sat t..uber)
(`) City
ows Dt. PEI tenth urpe
Tetra No 39 -511
N...* d bgty.l K f.rtivtfw :
Ynurvl PPrlr Hnspttat
(1t oath b.eMta1 or hatk.tte.. stet Argot .fir sr 1e0101w.
2. USUAL faWVIc$ OF NoTUti:
to acre. Plaid &a
al cam* Pine llaa
to cur ara.. litall..teratt
tr arsolwa.. .sr. £V 1.4
Wawa 20.1734 la t Ave. 3.
tty rant. ewe 1ra.Y..4
lkiwes.r bedew di.usf:
fa beech. Imolleotf.% t. 4F weusaady
(,patty, .loss(.., yews. ..sotto K fear.
MINN
t -r.7C
X f—
2L A7dr. bara to Mx usMbrr:
C (.) Ho. map OTHLP dillies se this amber e .o. Priem T
p
• y 9 (b) Ho. moray OTHER Andros .use bore Oho bat are weer dead T
Dr Ile) Hoe eats OTHai tiildret Are berg dead
C�
ao
'G v
t Dow of bMlb Jylf 1 9
law)
, 7 Male
CWILD
f- nn 99999 Bruce Grafton Carroll
10. Color or rasa ..h i is It. Mr at Woo at OD YAM. fro.
12. alrlbp4w Me bia• '1'eneaaaaa
(co,.t...srawaa) (tltrr.rf tafsatwtrs)
is. u..,..a�.u.. Deceased
14. Industry ar b.sisns
14. ,+,r .e1d....a uth rearm Ibr)
f<
Wars Yam 17. ash at Dowel tats bbti
.bawls. a
b... ar..�t,. tltreerammo Arai
it MINI - Hen aeti fa
,.. ts.awes or Weiner
s SAbrl. grim 64414.44. {ar s.ater.ri.. ..the:
0
0
0
22. 1 hereby certify that 1 att..id the birth of this dal, .bas 11 or n alive
Dues die.rs'b..)
date .love stated a.d tbst tut hfaeusatiw sires .as heraishol l
related to this ebad as mat i'1le r
war addolOpplarestal
(Dees en
Y
10243% ,
IL or ~we John I. Bardenberigh Nom
FL Iloilo=
me July 14 • T. 37 i M. Davis
Loa illialhdoee
STATE OF FLORIDA
COUNTY OF PINELLAS
i, WM. M. DAVIS, being first oluly sworn, do depose and say that the attached certificate is a
true and correct copy of th birth certificate of RILLIAX IIORLI IB CARROLL
on file and of trc itt the office of the LOCAL REGISTRA F VAT. TATISTIC
Srcokto itttZs qbedrUie f mti at St. Petersburg Pinellas County, Fl this th
* �.
:' -. u B gic
Local Registrar.
00
0.11'
}�,Public, l State pp�{ Florida.
Public, State of Flofidht large
My commission expires MY C°41.430011 ExPlies Mil Z4. 1945