Smith, Betty Jo (Skeen)Cemetery Call Work Sheet
Date: /
Funeral Home / Monument Company:
Contact Name:. °hate Loper Tel. #: �a-�- 51 8' a�6q Fax #:
('165 Farrzk,
Ave., Ave.� �lI e4rweitet, FL 3375(0
Reason for call: Staking Request (Interment/Disinterment)
t31k -7, Lot ��� P3�
(U) if
Monument (Marker) being placed (No fee for staking of
For:
V. Affidavit (Burial Rights)
Block Lot Space
Date: / / Time:
(Send email to P &R)
s 3k�
j. skceeK
j3 �%i. e B. S%e,en
monument) t
of Deity To
s ,4 ()
Verifying Burial space
✓ Other reason: for: B e t t y T v S A . . , 1+t ( Sk ee h)
Ry rlic Pa. ciarek
Interment: (One full burial and one urn, or two urns per space)
Full Burial
Owner of Plot:
Deceased Name:
Block Lot Space
Date of Birth: / / Date of Death / /
Urn Space
Date of Burial: / /
Time: am /pm
$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
r
Status of Block: 7 Lot: 18 as of 06/24/2015
INTERMENTS:
SPACE BURIALTYPE DECL
DECF
DECM BIRTH DEATH INTERRED
PERMIT
1 FULL GURLEY RALPH B 9/6/1912 07 / 22 / 1939 7/22/1939 0
2 FULL PACIOREK HENRY F 7/15/1921 07 / 10 / 1998 7/14/1998 2374
3 FULL SKEEN EDWARD J 9/12/1899 03 / 08 / 1958 3/11/1958 1322
4 FULL SKEEN BESSIE B 2/13/1900 05 / 17 / 1979 5/21/1979 1316
DISINTERMENTS FROM SPACE:
No Matching Records
REINTERMENTS:
No Matching Records
Page 1 of 1
1
1
INFORMATION REPORT FOR: BLOCK: 7 LOT: 18 SPACE: 3
CURRENT OWNER:
OWNER 1:
MYRTLE PACIOREK
SPACE TYPE:
CURRENT SALES INFORMATION:
DATE OF SALE: 7/11/1991
OWNER 2:
RELATION to OWNER 1:
DATE PAID IN FULL: 7/11/1991 AMOUNT OF SALE: $0.00
OR BOOK/PAGE: 763 / 7622 DATE RECORDED: 7/30/1991
PREINTERMENT INFORMATION:
None
INTERMENT INFORMATION:
DECEASED: EDWARD J SKEEN
INTERRED: 3/11/1958 :
BIRTH: 9/12/1899 DEATH: 3/8/1958
DIRECTOR: MOSS
NOTES: None
RIGHTS:
BURIALTYPE: FULL
PROCESSED:
PERMIT #: 1322
[CURRENT SALES INFORMATION: II
INFORMATION REPORT FOR: BLOCK: 7 LOT: 18 SPACE: 4
CURRENT OWNER: 11
None
None
PREINTERMENT INFORMATION: II
None
[INTERMENT INFORMATION:
DECEASED: BESSIE B SKEEN RIGHTS:
INTERRED: 5/21/1979 : BURIALTYPE: FULL
BIRTH: 2/13/1900 DEATH: 5/17/1979 PROCESSED:
DIRECTOR: MOSS EAST BAY PERMIT #: 1316
NOTES: None
DISINTERMENTS FROM THIS LOCATION :
None
OFFICIAL RECORDS AND
LEGISLATIVE SERVICES
June 24, 2015
Ms. Connie Loper
1765 Farrell Ave.
Clearwater, FL 33756
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 7, Lot 18, Spaces 3 and 4
Dear Ms. Loper:
Enclosed please find an affidavit prepared for your aunt, Betty Jo Smith (Skeen), for her
signature. This affidavit states that she is the descendant of Edward J. and Bessie B. Skeen
granting her the right to the property described above.
Once we receive the completed, signed and notarized affidavit we will update our records to
reflect this information.
If you have any questions, please give me a call at 727 -562 -4093.
Sincerely,
dith LaCosse
taff Assistant
Enclosure
"EQUAL EMPLOYMENT AND AFFIRMATIVE ACTION EMPLOYER"
AFFIDAVIT
STATE OF FLORIDA)
COUNTY OF PINELLAS)
I, Betty Jo Smith (Skeen), the undersigned, do hereby attest that I am the
descendant of Edward J. Skeen and Bessie B. Skeen, my father and mother, who are
buried in Block 7, Lot 18, Spaces 3 and 4 in the Clearwater Municipal Cemetery.
Please take this affidavit as your authority to note the right to property described
above. 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
Betty Jo Smith (Skeen)
SWORN TO and subscribed before me this day of
by Betty Jo Smith (Skeen) who produced identification in the form of
and who did /did not take an oath.
Notary Public
My commission expires: