Scarbrough, NoraCemetery Call Work Sheet
Date: / a3 / t01co
Funeral Home /
Contact Name:
Reason for call:
Monument Company:
Nora Scwt1r0(t
Tel. #: 737 - 391-573X Fax*
Staking Request (Interment/Disinterment)
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8885 93rd St
Affidavit (Burial Rights) 5eMt &' FL 33"177
Monument (Marker) being placed (No fee for staking of monument)
For:
Block Lot Space
Date: / / Time:
(Send email to P &R)
Verifying Burial space
Other reason:
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Interment: (One full burial and one urn, or two urns per space)
Full Burial
Owner of Plot:
Deceased Name:
Urn Space
Block Lot Space
Date of Birth: / / Date of Death / /
Date of Burial: / /
Time: am /pm
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$30.00 Staking Fee (Funeral Home) - received on: / /
Copy of permit emailed to Mark Tokar, cc: Cherise Sarnoff /P &R on: / /
******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Disinterment:
The following authorization should be obtained prior to disinterment:
1.) A disinterment permit and burial /cremation transit permit
2.) Written authorization from the individual(s) who currently own the burial rights
for the plot; and
3.) Written authorization from the individual(s) who would be permitted to authorize burial
Revised 11/24/14
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MAX . LARrIAR . WA.LLtR
1936 -1949
JAMES BONNER WALLER -
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CEMETERY BURIAL INFORMATION BY BLOCK/LOT /SPACE
BLOCK : 8 LOT: 50
DECEASED NAME: JAMES WALLER
BLOCK: 8 LOT: 50 SPACE: 2 BURIALTYPE: FULL
BORN: 05 / 16 / 1913 DIED: 07 / 3 / 1972 INTERRED: 08 / 02 / 1972
INTERMENT NOTES:
DECEASED NAME: MAX WALLER
BLOCK: 8 LOT: 50 SPACE: 3 BURIALTYPE: FULL
BORN: 11 / 01 / 1936 DIED: 12 / 24 / 1949 INTERRED: 12 / 24 / 1949
INTERMENT NOTES:
DECEASED NAME: RICHARD WALLER
BLOCK: 8 LOT: 50 SPACE: 4 BURIALTYPE: FULL
BORN: 01 / 01 / 1901 DIED: INTERRED:
INTERMENT NOTES:
LETTER OF INTERMENT RIGHTS FOR WALLER IN FILE - PACIOREK
* ** *END OF BLOCK : 8 LOT: 50 * * **
Page 52 of 98
OFFICIAL RECORDS AND
LEGISLATIVE SERVICES
March 10, 2016
Ms. Nora Scarbrough
8885 93rd St.
Seminole, FL 33777
CITY OF CLEARWATER
POST OFFICE Box 4748, CLEARWATER, FLORIDA 33758 -4748
CITY HALL, 112 SOUTH OSCEOLA AVENUE, CLEARWATER, FLORIDA 33756
TELEPHONE (727) 562 -4090 FAx (727) 562 -4086
Re: City of Clearwater Municipal Cemetery
Block 8, Lot 50, Spaces 1 -4
Dear Ms. Scarbrough:
Enclosed please find a copy of an Affidavit that notes the right to property for space 4 of Block 8,
Lot 50. Our records show that space 1 is reserved for your mom, Myrtle Paciorek.
Please give me a call at your convenience at 727 - 562 -4093 if you are in agreement with this
Affidavit.
Per the City of Clearwater Rules and Restrictions interment rights may not exceed two in
one space (one full burial and one urn; or two urns).
This document needs your mom's signature and you could be her witness. Once this document is
notarized, please return it to my attention, 112 S. Osceola Ave., Clearwater, FL 33756, Official
Records and Legislative Services Dept.
Sincerely,
J,L14,112-
*th LaCosse
taff Assistant
Enclosures
"EQUAL EMPLOYMENT AND AFFIRMATIVE ACTION EMPLOYER"
AFFIDAVIT
STATE OF FLORIDA)
COUNTY OF PINELLAS)
I, Myrtle Paciorek, the undersigned, am the owner of cemetery property described as
Block 8, Lot 50, Space 4 in the Clearwater Municipal Cemetery.
Please take this affidavit as your authority to note the right to property described below when
the need arises to my daughter, Nora Scarbrough, her son, Matthew Merle Scarbrough, and my
son, Richard Waller. Internment rights may not exceed two in one space (one full burial and
one urn; or two urns).
Block 8, Lot 50, Space 4: Nora Scarbrough, Matthew Merle Scarbrough or
Richard Waller
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: Myrtle Paciorek (Owner)
(Address)
Witness Relationship to Witness
(Address)
SWORN TO and subscribed before me this day of , 2016,
by Myrtle Paciorek who produced identification in the form of
and who did /did not take an oath.
(SEAL) Notary Public
My commission expires: