Stilwagon, LucienAFFIDAVIT
STATE OF FLORIDA)
COUNTY OF PINELLAS)
RECEIVED
OC T I 2024
CITY CLERK DEPARTMENT
I, Q n r t e n P Dot I l i o Tt , the undersigned, do hereby attest that 1 am the
descendant of Luc`tef. 5t:11wa9o4 , mygrPat ,roAdfaliter , owner of
Space(s) 7 of Block 4_, Lot 21 in the Clearwater Municipal Cemetery.
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
ee
e6;ey
2.047 PvivASetfic Ave
Ci ear w ate r, FL 3T755
813-837-q,g0
SWORN TO and subscribed before me this day of h.‘" , „2da-ci
by A,--1 6///0 t' who produced identification in the form of
A1-- G43-o/ci*.F07-4) and who did/did not take an oath.
FRANCISCO O. SOTO TOMES
Nptary Public
State of Florida
Commit HH184670
Expires 10/18/2025
Notary Public
mmissi n ex it
My co p es.