Paciorek, MyrtleD
Date: 3 /11 /a o o `1
Cemetery Call Work Sheet
Funeral Home/ Monu?ent gompa
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Contact Name:
Tel. #: G31_
Reason for call: Q e-e -ts es ti
il?owi oWKaA
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Fax #:
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D Qk 8 LVIt 50
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Deceased Name:
Date of Birth: Date of Death
Block Lot SID Space +
Owner of Plot: M t?lfikl- P,,--i ore k-
************************** ***********************************************************************
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)
to .. N o r? Sc o (A.T?_
7-2 7 o Prot- toe-,b
Afto S)
CITY OF CLEARWATER
POST OFFICE Box 4748, CLEARWATER, FLORIDA 33758-4748
CITY HALL, 112 SOUTH OSCEOIA AVENUE, CLEARWATER, FLORIDA 33756
'rELFPHONE, (727) 562-4090 FAx (727) 562-4086
OFFICL4I. RECORDS AND
LE.GISIATIVF. S}.RVICES
March 16, 2009
Nora Scarbrough
7770 Starkey Rd.
Apt. 108-D
Seminole, FL 33777
Re: City of Clearwater Municipal Cemetery
Block 8, Lot 50, Spaces 1, 2, 3 and 4 / Block 7. Lot 18, Space 2
Dear Ms. Scarbrough:
Enclosed please find a recorded copy of Cemetery Deed and Consent to Conveyance
between Mildred Marie Caldwell and Myrtle Paciorek regarding space 2 of Block 7, Lot 18.
The actual space transferred to your mom was space 2 (third space from the North) and not
space 3. Henry F. Paciorek is buried in space 2 of Block 7, Lot 18. A copy of other
documentation is enclosed.
According to our cemetery program your mom also owns spaces 1, 2, 3 and 4 of Block 8,
Lot 50. We do not have a copy of this deed in our files.
Also enclosed is a copy of an affidavit that needs to be signed by your mom granting
interment rights in space 4 of Block 8, Lot 50. This affidavit also needs to be notarized by
the appropriate individuals.
Please review this Affidavit with your mom. After we receive the signed and notarized
Affidavit we will then, 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
Enclosures
FRANK HIBBARD, MAYOR
GEORGE N. CRETEKOS, COUNCIL'NEMBER JOI IN DORAN, COUNCILMEMBER
PAUL F. GIBSON, COUNCILMEMBER ® CARLEN A. PETERSEN, COONCILMENIBER
"E(2LiAL BiPLOY,MENT AND AFFIRMATIVE ACTION EMPLOYER"
AFFIDAVIT
STATE OF FLORIDA)
COUNTY OF PINELLAS)
I, Myrtle Paciorek, the undersigned, owner of cemetery property described as Block 8, Lot 50,
Spaces 1, 2, 3 and 4 do hereby grant right of interment to my son, Richard Waller, in Space 4 upon
his death. Space 1 is vacant for future interment of myself. James Waller is buried in Space 2 and Max
Waller is buried in Space 3.
Please take this affidavit as authority to also grant interment rights for my daughter, Nora
Scarbrough, in Block 8, Lot 50, Space 4 in the Clearwater Municipal Cemetery upon her death.
We understand that the maximum capacity of a space is two burials provided at least one person is
cremated.
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 for the interment rights
request made.
SIGNATURE : Myrtle Paciorek (Owner)
(Address) 7770 Starkey Rd., Apt. 108-D, Seminole, FL 33777
SIGNATURE : Witness
Relationship to Witness
(Address)
SWORN TO and subscribed before me this day of , 200_3 by
known to me by
(SEAL)
personally known to me or has made herself
(identification).
Notary
My commission expires:
Dated:
INS •r # 91-203577 CEMETERY DEED AND CONSENT TO CONVEYANrF
,JI...Y ; 0, 1.9,T1 1 i23PM PINEL-L-AS COUNTY FL.A
?. ? OFI'= . f•,E C:. BK 7631 F'(3 6
THIS INDENT'CII E is made than 'day of I 19 between Mildred Mane Caldwell
as Grantor and Uyrd k whosolmailing address i ; 82 d Way N., Pinellas Park, FL 33565 of the County of
Pinellas, State of Florida, as Grantee:
WITNESSEM: That the said Grantor transfers ownership to Grantee and has remised, released and quit
claimed unto the said Grantee, and her heirs forever, all the right, title and interest which the said Grantor has in and
to the following described parcel of land, lying and being in Pinellas County, State of Florida, to wit: Space Throe(3)
(Third Space from the North), Loft 18, Block %, Clearwater Cemetery, as recorded in Plat Book 60, Page 30, Public
Records of Pinellas County, Florida.
This Conveyance is subject to the condition that Grantee herein shall not assign or convey said property without
the written consent of the City of Clearwater, Florida, and to the further condition that said property shall be used only
for cemetery purposes as human burial sites, and is subject to such other 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 and her
heirs and assigns forever.
written.
IN WITNESS WHEREOF, said Grantor has signed and sealed these presents on the day and year first above
(Signed, Sealed and Delivered (Grantor)
in the/presence L .CZ
State of Indian
County of L
Personally appeared before me Mildred Marie Caldwell to me well known to be the person wlip,;gecuted the
..foregoing instrument, and she acknowledged that she executed. d instrument as her free act and ?6k for the uses and
00 purposes therein expressed.
v~ s Witness my hand and official seal this day of 19?.
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53 CI&V
c: CONSENT TO CO ? " ' .,
h ,.
.
q The City of Clearwater, Florida, a municipal corporation, hereby consents to the conveyance of the above described
ijot, plot or parcel in Clearwater Cemetery from Mildred Marie Caldwell, the Grantor, to Myrtle Paciorek, the Grantee.
CA
IN VdTNESS WHEREOF, this Consent to Conveyance has en signed and sealed by the Mayor -Commissioner,
the City Manager, and the City Clerk, this 16 day of ( _, 1991
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(Signed, Sealed and Delivered
in th presence of u :
w 11 RECORDING
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NITr --
(Approved as to form and correctness)' PTG
P/C
-? C _
M. A. Gal 'th, Jr., Co At rney INT
TOTAL
OF CLEARWATER) , .
Michael J. Wright;,-" i anager
C?o i i i e Ae
4, r i
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Rita,iarvey; , 1VMayoriC6ulmis o ft`' , i,
Ate
est
`? Cyrikhia E. Cfo??aax1 CitX C(erT
State of Florida
County of Pinellas: ?,,; 'y { 1
t
Personally appeared before me Rita Garvey, Michael J. Wright, and Cynthia E. Goudeau,.to'me`well known to be
the persons who executed the foregoing instrument of conveyance in the capacity of Mayor-Commissioner, City Manager,
and City Clerk respectively, and they severally acknowledged that they executed said instrii went in their respective
capacity by and on behalf of and as the free act and deed of the City of Clearwater,;Floli`frfor, the uses and purposes
therein expressed.
ti
,19
eig,
Witness my hand and official seal at Clearwater, Florida this 16. day
This instrument was prepared by:
M. A. Galbraith, Jr., City Attorney
City of Clearwater, P. O. Box 4748
Clearwater, Florida 34618
Notary PUIlic, State of Florida
commission Expires April 20, iri93
Eond°d Thrm Troy Fain • In;L rLntJ Inc.
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June 27, 1991 1 r?
Mrs. Mildred Marie Caldwell
1609 S. 14th Street
Richmond, Indiana 47304
RE: Clearwater Municipal Cemetery, Block 7, Lot 18
Dear Mrs Caldwell:
Attached is a Cemetery Deed and Consent to Conveyance form to transfer
ownership of the above lot to Myrtle Paciorek. Please sign as the Grantor, have
it witnessed by two individuals and notarized and return the executed form to the
City. We will complete the Consent to,-Conv-eyanc-e portion of the form, have the
document recorded, and send it to Mrs. Paciorek. lease send the deed which
indicates you own this lot back to the--C_itya_1-ong- with the enclosed form.
If the deed you have indicates ownership to someone other than yourself,
we will need documentation, such as a will or signed affadavits from all
remaining family members, indicating you have the right to dispose of the
property.
If you have any questions, please feel free to call 813/462-6684.
Sincerely,
Susan Stephenson
Documents and Records Supervisor
SS/cm
Encl.
CERTIFICAT>. OF DEATH
. Elep inelst of Health and Rehahilitative Servir*s
• DIVISION OF HPaLTH F LfO R I D A.
H IIAaA.OF "FAIL nATatnv
WRITE FILE NO.
nrmRRvOAO, '_
vc?.cnJKV -?PVwC NR ST MIDDLE IA BY SEX DATE OF DEATH I MON(N, DAY, Yl AR 1
1. Harold William Storbeck 2. Male 2
July 9 1974
RACE WHI({, NlORO, AMERICAN INDIAN,
ETC. SP1cIFY 1
y .
AGE-1131, UNDER 1 YEAR Y DATE Of BIRTH IMONM, DAY CpL12.LTY DEATH -
51111`H ,Y?I YEARS 1 N
OS
7lAR 1
I
,
iL,e
,. 5b
. MII I.
se_ Sb. 1918
Pinellag
CITY, iO WN, OR LOIJIiIO R
- - IOR OTHER INSTITUTION-NAME ,, NOT
SP1CIn YES OIN EITN(f, GIVE STf!!T AND NUMBER I
n Lar o JE. Yes 9th Avenue S
W
STATE Of BIRTH I If Nor
COUNTRY .
.
CITIZEN OF WHAT COUNTRY NEVER MARRIED, SURVING SPOUSE I If WIFE
Gr1l MAIDEN NAME
1
e. Iowa ,
I
, DIVORCED ( SPECIFY I
USA oT
Jed
SOCIAL SECURITY NUMBER ?
,,.
USUAL OCCUPATION IGIVf RIND Of WORK DONE DUAING MOST of KIND OF BUSINESS OR INDUSTRY
WORKING LIF
1
12. 47 -14-6U1
E, EVEN If Rf 11R(D 1
13
Bus Driver
6.
1>V. 1y'at]$it Com
b.
RESIDENCE-STATE TccUNTY CITY, TOWN, OR LOCATION
cm LIMITS STREET AN
T loria a
A . Pin
FATHER 1 s?[UFY Yes OR No
ellas „{. IA'rgo I,d. Yes 114.
912-9th Street S
W
-NAME FIRST - .
.
.
MIDOI! LAST MOTHER-MAIDEN NAME FIRST
MloosE LAST
If. t•:Tilliam
INFORMANT-NAME F. Storbeck
* 116 Narguerite Bayless
MAILING ADDRESS (STREET 01 R.f.D. No., CITY OR TOWN, STATE, ZIP,
1_- ls.:T:arie Caldwell 1!6.1609-South 14th Street-Richmond Indiana-Z
PART I. ! 173 74
DEATH WAS CAUSED BY: (ENTER ONLY ONE CAUSE PER LINE FOR (D), (b), AND (c)1 A K MA I
le. IMMEDIATE CAUSE BE MEIN ONSET AND DEA
m Occlusive Coronary Artery Disease Years
DUE TO, OR A A CONSEOUENC 01:
CONDITI 0"" If ANY,
WHICH DAVE RI S[ TO (b)
IMMEDIATE CA US! 101,
STATING TN! 'J NDlI• DUE TO. OR AS A CONSEOUENCt OI:
LYING CADS[ 1151
ICI
PART It. OTHER SIGNIFICANT CONDITIONS: CONDITIONS CONTUSV1.NG TO DEATH BUT NOT fELAfEO TO CAUSE GIVEN IN PART I to) AUTOPSY IF YES well Timm as coo
IVIES DO NOI Stoma IN Ofrt1MINIMO CAUL
OE OCATM
IPTebcbl j ACCIDENT, SUICIDE OR DATE F INJU I MONTH, DAY, YEAR I HOUR -` I*- Iri.
HOMICIDE; OR UNDETERMINED HOW INJURY OCCURRED I EN114 «ATU" OF INJURY IN PART 1 02 PART N, IRM I$I
(Specify)
20IT 1,06. 2& M. Nd.
INJURY AT WORK PLACE OF INJURY AT HOME, FARM, sTR[FT, -Q." LOCATION
1 SPECIFY YES OR NO I OFFICE BLDG., ETC. (SPECIFY 1 1 STREET OR I.F.D. NO.. CITY 01 TOWN, STATE 1
2%. 201 Tee
CERTIFICATION- MONTH DAY YEAR MONTH OAT YEAR ANC UST SAW HW/ryFR ALIVE ON 1 010/DID NOT VIEW ME
- , ?NYSICIAN: MOIVIH DAY FOfAf" OCCURRED AT THE RACE, ON FILE
1 ATTENDED THE TO YEAR RCLOY AFTER DEATH. URI DATE, AND, TO ME Mel
DECEASED FROM 121b Of MY RN0WUD0l, DI.
CERTIFICATION MEDICAL EXAMINER OR CORONER: oN rNf EASIS of THE 21 L. M. To THE CAUUls1 3111,110
[KAMINOCATION Of THE BODY wN0/OR THE INVESTIGATION, IN MY OPINION, HOUR Of DEATH THE DECEDENT WAf'--.-CID DEAD
01ATP CURRED ON ME Dwrf AND DUE TO TNT CAUSf15) STATED. MONTH OAF YEAR HOUR
2211. Approx 3UR45 P. M.172b. July 9, 1974 4:15 P. M.
_ CERTIFIER-NAME InrE oR ru«n -
Roy L. Clemons, M.D. of-- on 1.71E DATE SIGNED IMONTH, DAY, TEARI
:3.. 1.6l esoc Med Exa
MAILTO Dg
• q?SS- CE.F
.D. o. uTY oR , WN m17k July 16 , 1974
21,. UUllmerV TIFIER on Road West STREET 01 A -F
Florida s-" 33540 ['P
BURIAL, CREMATION, REMOVAL CEMETERY OR CREMATORY-NAME LOCATION
1 SPECIFY 1 CITY on to.. MIT
24c Puri al 24b. Lari Cemetery 241. Largo Florida
GATE O«1,H, DAY, r u FUNERAL NOME-NAME AN ADDRESS I - r OE 1.1.0. N CITY OR / w« STATT, ZIP' 2u. Ju.ly 12, 1974 SR. Moss Funera? Home - 8( Nort?i Ft. arrison, Clearwater, Flori a
FUNERAL D GQR SIGNATURE
REGIST IGNAfUCF
OA E VEO Y IOCAI R?E/GISTRAR ?y
c. N Tt6. /
v
A CERTIFIED COPY MUST CARRY THE EMBOSSED SEAL OF THE REGISTRAR OF VITAL STATISTICS
I hereby certify that this is u true and correct copy of a certificate
on,file in the office of the Local Registrar of Vital Statistics of the
Pinellas County Health Department) St.,Petersburg, Florida„
JUL Deputy Local Registrar
17 1974
STATE HOARD OF HEALTH CERTIFICATE OF DEATH
BUREAU OF VITAL STATISTICS STATE FILE, NO. -
FLORIDA
REGISTRAR'S NO. - -
1. PLACE OF DEATH CODE NO. 2. USUAL RESIDENCE(R'Arrrdrewaardtirrd l!in.hlutmw: R-d-brf-d ....iawl
STATE b. COUNTY
a
a. COUNTY
Pi as .
r orida T rellas
b. CITY, TOWN. OR LOCATION [. IS PLACE OF DEATH
' c. CITY: TOWN, OR LOCATION e. IS RESIDE HCE
CITY LIMIfSr
INSICE
• INSIOE CITY LIMITS?
Largo YE56d NO? Clearwater tTpp
YES 11N NO [_1
it. NAME OF t(f not in hospital, gire 1lred addre n) d. STREET ADDRESS
HOSPITAL OR
• INSTITUTION Suncoast Os
teonathic Hos.nital
1x95 - South Greenwood Avenue _
_
3. NAME F First ,llUdle Last 1. DATE Month Day )'tar
DECEASED
(Type or print) Lelia Eunice Storbeck OF
DEATH December
13 1967
C] DATE OF BIRTH
B 9. AGE ((n Vtnrt IF UNDE R I YEAR IF UNDER It HRS.
5. SEX 6 COLOR OR RACE MARRIED ® NEVER MARRIED . I- bllfhda V) %f-(A. Dow Ifwr. 5f.w
Female
I•Ih:
WIDOWEDLJ DIVORCED
July 2!( 1918
U9 .
.
10a. USUAL OCCUPATION :rice kind al work dent 105. KIND OF BUSINESS OR INDUSTRY I I. BIRTHPLACE (.9nle or foregn country) IZ. CITIZEN OF WHAT COUNrRY?
during moil of u'arking lift, eren if rttirtd)
Fomemaker
Own Home
Dunnellon Florida
U.S.A.
13. FATHER'S NAME IA. MOTHERS MAIDEN NAME
(unknown) Robinson Irene (unknown)
16. SOCIAL SECURITY NO. IT INFORMANTS SIGNATURE Address lh95 - South Greenwood Avenue
255--20-3832c1t,?y? Clearwater Florida
IB CAUSE OF DEATH (Enter only one cause per lint f -r (n), r). q'id, 01
PART 1.-DEATH WAS CAUSED BY! INTERVAL BETWEEN .
ONSET ANQ DEATH
IMMEDIATE. CAUSE. (a) -???L-(---
Conditions. if any. DUE TO (6)?f'?.:??uJ7
rit
h
hi
t
,
Bare
w
c
e
o
abort enNae (a).
stating the under. OGE TO (e) -
lying emit last --f- -• - -- - --
O
- PART 11 OTHER SIGNIFICANT CONOITW.VS CONTRIBUTING )(9 0EATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART 1(4) 19. WAS AUTOPSY
PERFORMED!
1 YES ? NO
U
_
?
20a. tl'roasobl -
20b. DESCRIBE HOW INJURY OCCURRED. (P:nler nature of injury in Part.1 or Part 11 of item is.)
Of ACCIDENT SUICIDE HOMICIDE -
ki ? ? ?
20e TIME OF 1(aur ,%fonlh, DaV, )'ear
U INJURY a, m.
O p. M.
W
204.:NJURY OCCURRED
20e. PLACE OF INJURY (e. V.. In of 4h0nt home,
20f. CITY, TOWN. OR LOCATION - COUNTY
STATE
WHILE AT ? NOT WHILE ? 1
/arm, factory. street office bldg., t(e.)
WORK AT WORK 1
alive on -
ZI 1 attendcd tttc?daceased from? and lest saw her
Deal tS occurred of -2:25.-?' t_ _m on the date stated above; and to the best of my knowledge, from the causes stated.
( 224 G_HATUHE /??OtCr f 61Ule) 2Zb ADDRESS 22e. DATE SIGNED
-- ?- ??;/ _ / ??? ??:? , • Largo Florida
?I-el
2BURIAL CREMATION. 23h OAT 2k. HAMS OF CEMETERY OR CREMATORY 23d. LOCATION (City. faun. Of county) (Slattl
Rtm(Zi, 'L .tipec(/V1
Buria f 112-16-1967 Largo Cemetery Pinellas County Florida
24. FUNERAL (RECTOR S SIGNATU E [ ?r.nn 25. DATE RECD. BY LOCAL REGTJ PIS/TTRAR'S SIGNATURCora -o mneral Homed 5iC.?-?
lear?ater.1 rlori
I hereby certify that this is a true and correct copy of a certificate
on file in the Office of the Local Registrar of Vital Statistics of the
Pinellas County Health Department, St. Pet rsburg, Florida.
July 10, 1968'C'L?a ?C/•:''GZ,Deputy Local Registrar
eJ ear. ,c) tcO.an? L
ems- e .??. RPJ "4,LL ? 196 7
?A V?L die,
7/12/91
Dear Mrs. Caldwell,
We have concluded the transfer of cemetery property and are returning
your original documents to you.
Si erely T r ?,'
? [
Camille Motley
City Clerk Department
RECEIVED
U L 1 1 1991
CITY CLERK
August 13, 1991
Ms. Myrtle Paciorek
7822 72nd Way North
Pinellas Park, FL 34665
Dear Ms.4 f. sJ..
Enclosed is a deed and consent to conveyance which indicates
that you own Space'Lot 18, Block 7, in the Clearwater Cemetery.
This deed has been recorded in Official Records Book 7637, Page 662.
It is important to keep this deed in a safe place and to make
a separate note of the official record book and page numbers. In
the event the original deed is lost or destroyed, this information
will be needed to obtain a copy from the Pinellas County Clerk of
the Circuit Court.
If we may be of service in the future, please call upon us.
Yours very truly,
Susan Stephenson,
Documents & Records Supervisor
SS: em
Enc.
A' me- A
0
o,
=?'AT EP ??" ??
July 11, 1991
C I T Y OF C L E A R W A T E R
POST OFFICE BOX 4748
CLEARWATER, FLORIDA 34618-4748
Cynthia Goudeau, City Clerk
City of Clearwater Municipal Cemetery
P. 0. Box 4748
Clearwater, FL 34618
Dear Mrs. Goudeau;
Please take this letter as your authority to grant Right of Interment in the
following property at Clearwater Municipal Cemetery:
Permission is also granted to place a memorial on the site. Space: Space Three W (Third space from the North)
Lot No.: 18
Block: 7
For: Henry F. Paciorek
Very truly yours,
(Lot ner ' Myrtle Paciorek
(Lot owner)
AM
?? 7?(lt ._)f _
C I T Y OF C L E A R W A T E R
POST OFFICE BOX 4748
CLEARWATER, FLORIDA 34618-4748
July 11, 1991
Cynthia Goudeau, City Clerk
City of Clearwater Municipal Cemetery
P. 0. Box 4748
Clearwater, FL 34618
Dear Mrs. Goudeau;
Please take this letter as your authority to grant Right of Interment in the
following property at Clearwater Municipal Cemetery:
Permission is also granted to place a memorial on the site.
Space: Space One '(J) (North most space);.,
Lot No.: 50
Block: 8
For: Richard Waller
Very truly yours,
(Lot o ner) Myrtle Paciorek
(Lot owner)
1 I
' i •
t
9
,
J\j
\-, \- - I
/ ?,?AESSIE T. SKEEN
(?? May 21, 1979
JADWARD JULIUS SKE'N
Q ?l') 3-P-1958
3-
w
? T
?OCt(,A 7 of
14-
4W I I . pp-d- r?--rcd 7/? 9& pef)lkl
RALPH D. CU11118 Y
192 1939 `
r
J
r
F .
r
t ?a3??
LOT 50
N
VAX. LAPJLkR. WA.T IgH
isss-?s?s
JAMES BONNER WALLER
j,?,`? •8?- 7 2 -
S
u 5??--33oti?
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 / 31 / 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