Miller, DianaPropared by and Return to:
Judith LaCosse
Official Records and Legislative Services
City of Clearwater
112 South Osceola Avenue
Clearwater, Florida 33756
Tel: (727) 562-4093
CEMETERY DEED
KEN BURKE, CLERK OF COURT
PINELLAS COUNTY FLORIDA
!NST# 2010275552 09/29?2010 at 12:36 PM
OFF REC DBK: 17043 PG: EED RECORDING 6
DocType: $18.50
D DOC STAMP: $0.70
THIS INDENTURE made this 26 day of August , 2010, between
Diana Miller as Grantor, whose mailing address is
2841 E. Redwood Lane Phoenix AZ 85048 , County of Pinellas, State of Florida and the City
of Clearwater, Florida, a municipal corporation as Grantee:
WITNESSETH: That the said Grantor, for and in consideration of the sum of $10.00 in hand paid by the
said Grantee, the receipt whereof is hereby acknowledged, has remised, released and quit-claimed unto the said
Grantee all the right, title and interest which they said Grantor has in and to the following described parcel of
land, lying and being in Pinellas County, State of Florida, to wit: SPACE 4 LOT 18 ,
BLOCK 8 , Clearwater Cemetery.
This conveyance is subject to the condition that said property shall be used only for cemetery purposes as
human burial sites and is subject to such other rules and regulations the City of Clearwater may adopt pertaining
to use of said property.
TO HAVE AND TO HOLD the same to the only proper use, benefit, and behoof of the said Grantee
forever.
IN WITNESS WHEREOF, said Grantor has hereunto set his hand and seal the day and year first above
written.
Signed, sealed and delivered in our presence:
Witness Signa re
Print Name:
Name
Grantor
Witness Signature
Print Name:
STATE OF ZhOTC= )
COUNTY OF?
The foregoing instrument was sworn to, subscribed to, and acknowledged before me this
1 P .-
day of
t=MVt?t , 2010 by who has produced the following identification
0_X10 /is personally known to me.
3
i
Signature (Person taking acknowledgement)
Notary Name (Printed, typed or stampe(l)
(SEAL)
Approved as to form:
Leslie K. Douga -Sides
Assistant City Att y
Frank V. Hibbard
Mayor
William B. Horne
City Manager
kosemarie Call
City Clerk
OFFICIAL SEAL
ANDREW PEARSON
Notary Public - State of Arizona
MARICOPA COUNTY
My Comm. Expires Sept. 3, 2014
'fie,
sue. { ? r
• Cemetery Call Work Sheet
Date:
Funeral Home / Monument Company:
Ott Q?
Contact Name: Tracie? -
Tel. #: - Fax #: 8 ? "? - S 8 5 - `f o k ?0`f
Reason for call: MS - A! kaz4, f?
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Deceased Name: Mores..sr'?f
Date of Birth: Date of Death
• Block g Lot Space ?- ?$`Fl ?. 2?d?ao? L?•.e ??¢?` '
(?.o ems.; Jc l A Z ? 5 d ????
Owner of Plot: 'f 8
u?k?o ???-?
Interment: (One full burial and one urn, or two urns per space)
Full Burial Urn Space
$30.00 Staking Fee - received on: / /
Date of Burial: Time: am/pm
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
Monument Being Placed: (No Fee for Staking of Monument)
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Authorization For Disbursement Date:9/29/2010
Time:2:38 PM
Vendor/Payee name: Diana Miller
2nd line vendor/payee name:
Remit to: Street / PO Box 2841 E. Redwood Lane
Remit to: City, State, Zip Code Phoenix, AZ 85048
Purchase orders are required for payments in excess of $2,500.
Purchase Orders are required if prior year payments or expected payments have or will exceed $2,500.
P.O. NUMBER (if required) RELEASE # RECEIPT #
Provide a description or reason for this expense:
City of Clearwater paying $10.00 for donation of cemetery plot from Ms. Miller.
If you are charging more than one account please
provide additional description for each account:
CHARGE TO ACCOUNT #
AMOUNT TO CHARGE
1 Payment for Plot 010-09700-550400-513-000 10.00
2 0.00
3 0.00
4 0.00
5 0.00
6 0.00
7 0.00
g 0.00
g 0.00
10 0.00
11 0.00
12 0.00
13 0.00
14 0.00
15 0.00
16 0.00
Grand Total $10.00
.l- Full Signature I of person authorized to sign Purchase Order Receiver Copy:
Print Name and Title of person signing Rosemarie Call, City Clerk
Print this form and attach the original document(s) that validate the amount you are requesting payment for. Attach
any copies that must be sent with the check. Improperly completed forms will delay check request.
ng the Finance
Departtment not to mail check to the vendor.
Please explain below if you are requesti
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Keyed
Created by W.M. Tedder AFD
City Clerk Document # 9821-0002
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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
OFFICIAL RECORDS AND
LEGISLATIVE SERVICES
October 13, 2010
Diana Miller
2841 E. Redwood Lane
Phoenix, AZ 85048
Re: Block 8, Lot 18, Space 4 - Clearwater Municipal Cemetery
Dear Ms. Miller:
Enclosed you will find the original recorded copy of the Cemetery Deed in
which you have remised, released and quit-claimed above referenced plot unto
the City of Clearwater. Along with this deed is a check in the amount of $10.00
from the City of Clearwater for your donation of this plot.
If you have any questions, please contact me at 562-4093.
Sincerely,
zt j?&44.e_
udith LaCosse
Staff Assistant
Enclosure(s)
AIN
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Ll1UAL biPLOYMPNT AND t1PFIR4IATIVE AC 710N MPLOI'GR