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MacMillan, Dorothy E OFFICIAL RFCORDS AND LEGISIATIVE SERVICES CITY OF C LEARWATE R Posr OFF-IcF: Box 4748, CLGARWATF;R, FI_oHn)A 33758-4748 C Tl }MALL, 112 SOU I H 0S(.:EUTA AW-NUE, CLEARWATF.R, FLORIDA 33756 Tri.EPiiomF (727) 562-4090 FAx (727) 562-4086 February 2, 2004 Dorothy E. MacMillan 5627 E. Anna Jo Drive Inverness, Florida 34452 Dear Ms. MacMillan: We received your signed form, "Consent to Conveyance", deeding Spaces 3 and 4, Lot 9, Block 7 to Jacqueline Walker. Since you are deeding the spaces to your daughter on one document, the charge is $25, plus a recording fee of $14. To complete this transfer, please send your check, payable to the City of Clearwater, in the amount of $39. If you have any questions, please contact me at 727-562-4091, or you may also contact Susan Stephenson at 727-562-4097. Sincerely, Lois . Norman Senior Staff Assistant to the City Clerk RECEIVED FEB 0 .?? zoos BRLANJ. ACNG.YI, K????R-Cu:?s,+?I iInnFR HOtirr HA:'1111,10N, Vir.l? ?1SV(?R-E;??.?+?+rssu?Nr:R WHI):RFV (I'MY, COMMISSIONER ['RA.NK HIBBARD, L,t),?i?,U551<>;irlt ® fill.]. )ONS4)N, C ONIMISSIONER EMP1l WbIF N r Axn A> FIR,NIATrnvl_ Ac rlOti Enil>Lavrx?? pug ? 9 ov OFFICIAL RECORDS AND LEGISLATIVE SERVICES C ITY OF C LEARWATE R 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 February 2, 2004 Dorothy E. MacMillan 5627 E. Anna Jo Drive Inverness, Florida 34452 Dear Ms. MacMillan: We received your signed form, "Consent to Conveyance", deeding Spaces 3 and 4, Lot 9, Block 7 to Jacqueline Walker. Since you are deeding the spaces to your daughter on one document, the charge is $25, plus a recording fee of $14. To complete this transfer, please send your check, payable to the City of Clearwater, in the amount of $39. If you have any questions, please contact me at 727-562-4091, or you may also contact Susan Stephenson at 727-562-4097. Sincerely, Lois . Norman Senior Staff Assistant to the City Clerk In BRIAN J. AUNGST, MAYOR-COMMISSIONER HOYT HAMILTON, VICE. MAYOR-COMMISSIONER WHITNEY GRAY, COMMISSIONER FRANK HIBBARD, COMMISSIONER ® BILL JONSON, COMMISSIONER "EQUAL. EMPLOYMENT AND AFFIRMATIVE ACTION EMPLOYER" CONSENT TO CONVEYANCE THIS INDENTURE is made this 30 day of , 200Y between DOROTHY E. MACMILLAN, as Gra r and PURCHASER(s), whose mailin address is S-33 _p c ,? L . of the County of e //a s State of (/,-, , as Grantee: WITNESSETH: That the said Grantor transfers ownership to Grantee and has remised, released and quit claimed unto the said Grantee, and 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: Spaces three(3) and four (4), Lot Nine (9), Block Seven (7) 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 heirs and assigns forever. IN WITNESS WHEREOF, said Grantor has signed and sealed these presents on the day and year first above written. (Grantor(s) name:) (Grantor(s) address.) (Name of Seller)^ ?t?r? G? i/ /., . M a C_ P? "Z' G? /1 ?/U 1) ino-? e< . f / . -3 ?? S Z (Name of S ller) (Witness (2) Signed, S led a '&De'ered (Witn ss) names nd a re es) in ese Ce of us: te' Q z r ( .304 q6. (ndi5qy type/print) v1/ STATE OF !=(02t) COUNTY OF Ci` P-05- ) k1 V&-P" ?- 3 Acknowledged before me on this day of `) 20 , by ODr +-f ?h it ? who personally known to me or has produced as identification and who did take an oath. v I P Robin T Vanslette ry (SEAL) ? "? Notary Public y, My Commission DD029199 -Roo 1/7 Print/type name: F.ywes May 28, 2005 " ??`?5 CONSENT TO CONVEYANCE The City of Clearwater, Florida, a municipal corporation, hereby consents to the conveyance of Spaces 3.and 4, Lot 9, Block 7, Clearwater Cemetery, from the Grantor: to the Grantee. IN WITNESS WHEREOF, said Grantor has caused these presents to be executed in its name by its Mayor Commissioner, by its City Manager, and to be attested and its corporate seal affixed by the Deputy City Clerk on the day and year first above written. Countersigned: CITY OF CLEARWATER, FLORIDA Brian J. Aungst, Mayor-Commissioner By: William B. Horne, II, City Manager Approved as to form: Brian Ruff, Assistant City Attorney Attest: Susan Stephenson, Deputy City Clerk STATE OF FLORIDA ) COUNTY OF PINELLAS) Before me personally appeared Brian J. Aungst, the Mayor-Commissioner of the above named city, who acknowledged that he executed the foregoing instrument. He is personally known to me and did not take an oath. WITNESS my hand and official seal this day of 20_ (SEAL) Notary Public STATE OF FLORIDA Print/type name: ) COUNTY OF PINELLA,S) Before me personally appeared William B. Horne, II, the City Manager of the above-named city, who acknowledged that he executed the foregoing instrument. He is personally known to me and did not take an oath. WITNESS my hand and official seal this day of 20_ (SEAL) Notary Public Print/type name: CONVEY. DOC 9700-0031 Rev. 5/96 CONSENT TO CONVEYANCE THIS INDENTURE is made this day of , 200_, -o*-- IMPORTANT between DOROTHY E. MACMILLAN, as Grantor and PURCHASER(s), whose mailing address is State of , as Grantee: of the Canty of IMPORTANT WITNESSETH: That the said Grantor transfers ownership to Grantee and has remised, released and quit claimed unto the said Grantee, and 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: _Spaces three(3) and four (4), Lot Nine (9) Block Seven (7) 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 heirs and assigns forever. IN WITNESS WHEREOF, said Grantor has signed and sealed these presents on the day and year first above written. (Grantor(s) name:) (Grantor(s) address.) -E- IMPORTANT (Name of Seller) (Name of Seller) r? (Witness (2) Signed, Sealed and Delivered in the presence of us:) (name type/print) STATE OF ) COUNTY OF ) Acknowledged before me on this to me or has produced (SEAL) Notary Public Print/type name: CONSENT TO CONVEYANCE The City of Clearwater, Florida, a municipal corporation, hereby consents to the conveyance of Spaces 3 and 4. Lot 9, Block Clearwater Cemetery, from the Grantor, to the Grantee. IN WITNESS WHEREOF, said Grantor has caused these presents to be executed in its name by its Mayor Commissioner, by its City Manager, and to be attested and its corporate seal affixed by the Deputy City Clerk on the day and year first above written. Countersigned: CITY OF CLEARWATER, FLORIDA Brian J. Aungst, Mayor-Commissioner Approved as to form: Brian Ruff, Assistant City Attorney (Witness) names and addresses) -*--- IMPORTANT day of 20_, by who personally known as identification and who did take an oath. By: William B. Horne, II, City Manager Attest: Susan Stephenson, Deputy City Clerk STATE OF FLORIDA ) COUNTY OF PINELLAS) Before me personally appeared Brian J. Aungst, the Mayor-Commissioner of the above named city, who acknowledged that he executed the foregoing instrument. He is personally known to me and did not take an oath. WITNESS my hand and official seal this _ day of , 20_ (SEAL) Notary Public STATE OF FLORIDA Print/type name: ) COUNTY OF PINELLAS) Before me personally appeared William B. Horne, II, the City Manager of the above-named city, who acknowledged that he executed the foregoing instrument. He is personally known to me and did not take an oath. WITNESS my hand and official seal this _ day of , 20_ (SEAL) Notary Public Print/type name: CON V EY. DOC 9700-0031 Rev. 5/96 a?,&I0' ? gje?dd®? t.1R, OFFICIAL RECORDS AND LEGISLATIVE SERVICES 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 December 5, 2003 Dorothy E. MacMillan 5627 E. Anna Jo Drive Inverness, Florida 34452 Dear Ms. MacMillian: Thank you for your letter with a copy of the original deed for Lot 9, Block 7 for the Clearwater Municipal Cemetery, as well as the copy of your mother's will. In reviewing the purpose of your request to transfer ownership of the two spaces (3 and 4) to your daughter, Jacqueline, we suggest one of the two following procedures. You may complete an affidavit to grant burial rights to use the spaces; this would be at no cost to you. The affidavit is attached. If you want to deed the spaces to your daughter, the cost would be $25.00 per deed plus a recording fee of $14 each. Your total cost would be $78.00. Please confirm your preference. If you wish to grant burial rights, complete the attached affidavit. If you wish to transfer ownership by deed, please send a check in the amount of $78.00, payable to the City of Clearwater. If you have questions, you may contact us at 727-526-4091. Sincerely, Lois orman Senior Staff Assistant to the City Clerk In Attachment BRIAN J. AUNGST, MAYOR-COMMISSIONER HOYT HAMILTON, VICE MAYO R-COMMISSIONER WHITNEY {DRAY, COMMISSIONER FRA,4K HIBBARD, COMMISSIONER BILL JONSON, COMMISSIONER "EQUAL EMPLOYMENT AND AFFIRMATIVE ACTION EMPLOYER" RECEIVED DEC 03 2003 Dorothy E. MacMillan OFFICIAL RECORDS AND 5627 E. Anna Jo Dr. LEGISLATIVE SRVCS DEPT Inverness, Fl. 34452 Phone: 352-341-0113 November 30, 2003 City of Clearwater Official Records And Legislative Services P.O. Box 4748 Clearwater, Fl. 33758-4748 Attn: Lois Norman Enclosed please find a copy of the original deed for Lot 9, Block 7, Clearwater Cemetery in the name of C. E. Howard. Two of the burial plots have been used by my infant sister and my mother Nancy Virgie Howard who passed away June 201h 1993. Mr. Howard passed away in February 1993 and was buried in California. Being the sole heir of Mrs. Howard, the remaining two plots have been passed on to me through the deed and my mother's last will and testament. I have made arrangements to be cremated and entombed with my husband in the Bushnell National Cemetery and I would like to transfer the ownership of the remaining two plots to my daughter, Jacqueline L. Walker. I understand that there is an affidavit that must be endorsed through your office to get this accomplished. I am enclosing a copy of my mother's will, her death certificate and Mr. Howard's death certificate. My former name was McClamma when the will was written. I have been divorced from Curtis McClamma since 1975 and married to Lawrence K. MacMillan since June 21" 1975, attesting to the name change. Please forward the required affidavit to the above address. If you have any further questions in regards to this matter please feel free to call me at the above number. Thank you for your assistance in this matter. Sincerely, V Dorothy Edwina MacMillan 5627 E. Anna Jo Dr. Inverness, Fl. 34452 + THIS INDENTURZE, Nl;ade fIli-, day of l.aaz't-h A. D., 19 44 Between the City of Cleur%vat,-r, Fktrida, a tncrnicip ll Iwpfu?atiou crtated arn.i t ?;i tiny under the laws of the State of Florida. part.,y t)f tilt, fir;.. Dart, ;tntl r% •,, flc??'vix'd of the County of PiAt? .I State of iell ?r lr.?rf Y Of the second part: WITNESSETH: T;-)ai? i,ir!? ??aid ;:ar4v ut' 'lit, J'ir t hart, f(it, ;tnd ill (-Ow<iderxa!on of the sum of 80 • 0 `" , to it ill it;arld pal([ 1," tl!e "aid ftaOy t)f file 'econd hart. the rtrceipt whereof is hereby acknowledged. h;t , reltli =ctl. re?lt?asrti, and tlllit-t:lairtrad. tltito fl-lo :+aitl ltarty of the second part, and Ili` z;irii =t,sil in 4 fm-c\er, ;tll tl)e ri' ht, tif.lP ;Md int(rt'st Nvhich the said party of the first part hay in ;:nd to f i 1'()llowing di,-,crillo l lot, tracfi. or hart of Ili' hand, lvhig and being. in Pinellas County. to w;t: -k "It- --viater TO HAVE AND TO 11Wi I) t_itt, .ua)r)t to the t)uly proper wzv, hctlefit. and i)ehoof of the said part Y _ of the se:?ond part IN WITNESS W1rlEI P'(iF, -;aitl (' 1c ))f CI<;trtt;afcr, it municipal corpor;ttion. !-as caused these l}resents to Be cxuctili,l ill iti- [)writ' 1)3" its M t}'t)1' (?nitiall.ti?It)nPr, l)y its Cill' Mzowler, and to be at- Lested and its Co;pot?tte i1. t'io _ludit(r sautl ('10rk or) fhi?: tl,c d<o- and year first above written. Signed, Sealed and Deli-, erod in the presence of ;t C ITV OF UI, , TER, FLORIDA. h ,ity Manager. i'otrniersihnea u yor Commission _. Atte City Auditor ;&Clerk. State of Florida, ' +^ County of Pinellas: \ ?' ?? ?? • a a ?j f':,1 V ?'? ?'' .I? • 11F? iltt S' 1:? Personally appeared lr 4ol- n w, and i''ran.k 1.;c)o1ey !.: Me n+ 11 kiat),rrl to he the persons who executed the forep'oinf. 1)l,?tt'iilnont. tit kitmo.vanct' ill tilt' cal)acit1 tri M Ivor Ct)l,"tlrrissloner, City Man- agrer, City Auditor and C'lork 1°e?jlet t ?. t l??, ;Anti t ht"V 1 lt;at, Hey executed said instrument in their respet,tivt- capacitV bti- <ltul t)n 1)t'l,xll Of anal as the free zt t and deed of the City of Clearwater, Florida, a naunrr,r);'1 t't?!'ltt)r<iilt7n. for l1w Ilso's atl(i l)urpos('ti tht'I'k`f11 ey1)re,S,'ed• Witness my ham'and oft`?e?i,d -;ti :at Clot tr%v;tlel% Vlorid;l, dais the t;:i-)lfI' day of r to h A. 1). P) Aj? J?;. t 'fF r.a` ?"?f (Seitl? Nol.iry Publ' Statue of Florida. I? ?t)t),lnissic,n c?xp;re i,,p; '•1945. '?O,.rrq?ra?llrow,,i?lip.,rr,wa,MSa?U.'?rr:Yr..,??•i.?itb as•?w.,a?r.o.n ,w ,rr???w •s..®». a,. W,?.,.?.,,r.:..,,?....w l ? LAST Will AND TESTAMENT OF MANC Y V I_RG LE HOWARD . -tA'i k til? FI_,OR M t I'INL;Li,rl`? ) i'111iPd'i'?' OF ?i 1, NANCY V1RGIE HOWARD, of 724 Tuskawi lla, Clenrwnt_or. ki -I ins-: ( )unty, F1oridi, IMPi-n, of sound and 0sposing mind., I? ?i lilOItl"I rend underiwUndi_ng, considering the certainty of death :111(1 it,,, is weri-n i ntv of the I imp thereof, and desiring to settle my `:'ord l v n l N i rs in the manner seeming to tale the best before it pl -, s-s Almighty God to coal 1 me hence, do make, publish and dvrlnre !he Following as my Last Will and Testament, that Ls I " Sa', : FIRST: I c(mnilli t. my soul, unto t he hands of Al-mi ghty (:(,(-i, who? gave it, and my body to t he eart h to be decently b"r1pd in i1w Clearwater Cemetery. SECOND: i give, de` i-se and beg"eath my e"Clue est_nte :alld 1)vop('I-ty, wheresoever si tu.gte and wheresoever -found to my I,(, I r,-,iod d;in ght er, MHO THY l' DWi NA McCIAMIA, in fee simple, flip "lui el v and Forever. THIRT I hereby nominate, constitute and appoint IwRt1THY FI)WINA McCIAMPIA as Executrix A this my Last Will and tes,t_rlment :Ind request. LOU she he permitted to serve in that crl Inc i tv wi.i. houtthe "Pees s i ty of giving bond. IN WITNESS l^JIWRVOF, i have hereto set my hand and son] i leis: rlrly A(af?rl,:t, in the vear o[ our Lord, ogle thous;,iud i? i 11?` Ili tip=11"(mod and i I S i ?. . (SEAL) ...., , ? 11 -1 Tho for e;;oi_nf; i_n ;t.rument, of which this is the second I :rnd (? i na 1 i?.rf;e, v7ns signed, seated, declared and published t,?% FLAMM' ??[KGfI? HOWARD, as hvr Last Will and Testament, in the i?r?':,r?nce OF us, t_Im u"dnrsigned, who at her special instance li i. "T"M , do attest ns w! Messes, aft._er said testatrix has !? r t S?11??d hor name thereto, and i" her presence and in the presence ?I of Prich oIher, and written opposite our names our respective II pwcps or rQsrdencp. 4. G .. -*.l'.?' '.'.•?.. r r . yr r. r r r rw r... v w . ., :.' STATE OF CALIFORNIA DEPARTMENT OF HEALTH SERVICES 1 Y l 3 CERTIFICATE OF DEATH STATE OF CALIFORNIA 3-93-49-000379 IICF Fu ACK INK ONLY LOCAL REGISTRATION DISTRICT AND CERTIFICATE NUMBER NAME OF DECEDENT-FIRST 10. MIDDLE IA IC. LAST (FAMILY) 2A. DATE OF DEATH-Mo, DAY, YR 12B. HOUR 3. SEX . (GIVEN) d SR H 1993 12400 M 6 Februar Charles I Edwin . owar , y 4. RACE S. HISPANIC-SPECIFY 6 DATE OF BIRTH-MO, DAY, YR . 7. AGE IN IF UNDER 1 YEAR IF UNDER 24 HOURS White ? YES ® NO e tember 19, 1909 S YEARS MONTHS DAYS 83 HOURS MINUTES DECEDENT 8. STATE OF 9. CITIZEN OF WHAT IOA. FULL NAME OF FATHER It OB. STATE OF i IA. FULL MAIDEN NAME OF MOTHER 118. STATE OF PERSONAL DATA BIRTH COUNTRY BIRTH ^ BIRTH Blanche Cornelius NC P3C r`1,Zar1 e.;; He and r?^ ^ Tr __ _ _ 12, MILITARY SERVICE7 13. SOCIAL SECURITY NO _ 14. MARITAL STATUS 15- NAME OF SURVIVING SPOUSE (IF WIFE, ENTER MAIDEN NAME) 19 -2-6 To 192-9 [:1 NONE 266-16-6073 Married Hazel L. Hutchinson 16A. USUAL OCCUPATION 16B. USUAL KIND OF BUSINESS 16C. USUAL EMPLOYER 16D. YEARS IN 17. EDUCATION-YEARS COMPLETED I '-. - OCCUPATION 1 OR INDUSTRY Supervisor i Dairy !Knudson Creamery 19 12 18A. RESIDENCE-STREET AND NUMBER OR LOCATION I 18B. CITY O 118C. ZIP CODE USUAL 2791 McBride Ln. #180 Santa Rosa :95403 RESIDENCE 18D. COUNTY 1BE. NUMBER OF YEARS 18F. STATE OR FOREIGN COUNTRY 20. NAME, RELATIONSHIP, MAILING ADDRESS I AND ZIP CODE OF INFORMANT 1 IN THIS COUNTY Sonoma 0 ; California Hazel Howard - Wife PLACE OF DEATH 19B. IF HOSPITAL, SPECIFY 19C. COUNTY 2791 McBride In. #180 19A . ONE: IP_ER/OA, DOA noma Santa Rosa, CA 95403 S PLACE o Creekside Convalescent OF 19D. STREET ADDRESS-STREET AND NUMBER OR LOCATION 19E. CITY TME I INTERVAL 22. WAS DEATH REPORTED TO CORONER? DEATH R BETWEEN ONSET REFERR UMBER 93-?Y31 ?X osa 850 Sonoma Ave. Santa AND DEATH ND YES ' 21. DEATH WAS CAUSED BY: (ENTER ONLY ONE CAUSE PER LINE FOR A. B, AND CI I I 23, WAS BIOPSY PERFORMED? IMMEDIATE (A) CARDIAC ARREST , ?IMIZED. ? YES © NO CAUSE 24A. WAS AUTOPSY PERFORMED? CAUSE I OF ' iIM!4ED. CARDIAC ARRHT THrIIA ? Y S ? NO DEATH (B) ......... E DUE TO 24B. WAS IT USED IN DETERMINING CAUSE 1 0 YRS x OF DEATH??-? . 13 DUETO (c) ATHEROSCLEROTIC CARDIOVASCULAR DISEASE ? YES !-1 NO 2S. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO CAUSE GIVEN IN 21 26. WAS OPERATION PERFORMED FOR ANY CONDITION IN ITEM 21 OR 25? IF YES. LIST TYPE OF OPERATION AND DATE. NONE 27D. DATE SIGNED 1 CERTIFY THAT TO THE BEST OF MY KNOWLEDGE DEATH 278- SIGNATURE AND DEGREE OR TITLE OF CERTIFIER 27C. CERTIFIER'S LICENSE NUMBER PHYSI- 1 OCCURRED AT THE HOUR. DATE AND PLACE STATED FROM THEl ./I 1 ^A` / -P " 2 9 93 86 CIAN'$ CAUSES STATED. (, ` - I G 01 15 1 - CEI DECEDENT LAST SEEN ALIVE' CERTIFICA- 27A. DECEDENT ATTENDED SIN MONTH, DAY. YEAR MONTH. DAY, YEAR ; 27E. TYPE ATTENDING PHYSICIAN'S NAME AND ADDRESS TION Sheldon Weiss, MD "3851 Montgomery Dr. Santa Rosa, CA 11 30 92 ' Ol 11 93 ' I CERTIFY THAT IN MY OPINION DEATH OCCUPIED A 28A. SIGN :'.TU ^E ANA T,7. ?F CORONEP OR DEPUTY CORONER ? 28B. DATE SIC-NEC THE HOUR, DATE AND PLACE STATED FROM THi CAUSES STATED. I CORONER'S 29. MANNER OF DEATH-Speci4 one: natural, accident, 30A. PLACE OF INJURY i 30B. INJURY AT WORK 130C. DATE OF INJURY 31. HOUR USE suicide, homicide, pending investigation or could not be determined MONTH, DAY. YEAR ? ? ONLY YES NO I l 32. LOCATION (STREET AND NUMBER OR LOCATION AND CITY) 33. DESCRIBE HOW INJURY OCCURRED (EVENTS WHICH RESULTED IN INJURY) 348. PLACE OF FINAL DISPOSITION-NAME AND ADDRESS 34C. DATE 34A. DISPOSITION(S) 35A. SIGNATURE OF EMBALMER 358. LICENSE 1 FUNERAL 1 I MO. DAY, YEAR Santa Rosa, 1 NUMBER I DIRECTOR CR RES 12791 McBride Ln. #180.CA I -- Not Not Embalmed I AND 36B. LICENSE NO. 36A. NAME of FUNERAL DIRECTOR (OR PERSON ACTING AS SUCH) 37. SIGNAT RE OF LO RAR 38. REGISTRATION DATE LOCAL 1 -- 1 FEB 1 1 1993 REGISTRAR Neptune Society - Santa Rosal F1334 10, ?v A. B. C. D. E. F. CENSUS TRACT STATE REGISTRAR VS-11 (REV. 3-91) This is to certify that this document is a true copy of the official record filed with the Office of State Registrar. Molly Joel Coyne, MD, MPH, Director and State Registrar of Vital Statistics 754043 by, /?'_aa?C. '119 D,J a.uTA MICHAEL DAVIS, CHIEF DATE ISSUED OFFICE OF STATE REGISTRAR M?R Q? This copy not valid unless prepared on engraved border displaying seal a. s g6natl2'Ei1?Registrar. p M?1MIR, '? ? Kr.If„ rlvKif le. ? 'til i OFF 4xi ICE of VITAL STATISTICS *r, t CERTIFIED COPY. 09 l IN .?. ANENT cERnFIcArE of DEATH K INK LOCAL FILE NO. FLORIDA 1. DE'CEDENT'S NAME FIRST MIDDLE LAST SEX 2 Nancy Virgie Howard . Female 3' DATE OF DEATH (Month, Day, Year) A SOCIAL SECURITY NUMBER 5a. AGE•Last Brithif" 5b. UNDER 1 YEAR 5c. UNDER 1 Day _ June 20, 1993 265-62-8472 ryes-s) 8 3 Months Days Hours Minutes , _ 6. DATE OF BIRTH (Month, Day, Mar ) 7. BIRTHPLACE (City and Stall or Foreign Country) 8. WAS DECEDENT EVER W U S t b . . ARMED FORCES? (Yes or No) ! 6i i4n? em er 21, 19 09 ty, Mad Coun Florida No 9a. PLACE OF DEATH (Check only one. see instructions on o ther side) 9b. INSIDE CITY LIMITS? ribs or Nei / ..HOSPITAL: Q Inpatient 0 ER/Outpatien 9c FACILITY N i ? DOA OTHER;D Nurscq Home 0Residence pother (Specify) Yes K . AME (H not inshfutron, p ne street and number) 9d. CITY, TOWN, OR LOCATION OF DEATH 9e. COUNTY OF DEATH Cypress Cove Care Center Crystal River Citrus " E KIND OF IX DONE 10a. DECEDENT'S USUALpCCUPAT1pN 10b. KIND OF BUSINESSANDUSTRY 11. MARITAL. STATUS -Muriel, 12. SURVIVING SPOUSE (t wib, give maiden name) `?`" $>I itNG MOST ? NOT Never Married, W idowed, Divorced($/Jaq(y) q?i4S RETIRED. Homemaker. Own.. Home: Widowed. 13a. RESIDENCE - STATE 13b. COUNTY 13c. CITY, TOWN, OR LOCATION 13d. STREET AND NUMBER Florida Citrus Crystal River 8700 W. Candleglow St. ire. INSIDE CITY 13f. 21P CODE 14. WAS DECEDENTOF HISPANIC OR HAITIAN ORIGIN? t5. RACE - American Indian, 16. DECEDENT'S EDUCATION LIMITS? (,1s a kbl (Specfy No or Yes - If yes, specify Nathan, Cuban. Black, White. etc. (Specify only highest grade completed) Mexican, Puerto Rican, etc) N o 3 4 4 213 ,dfy %No awe sue" White ;o . ,"^rpa+ or s . ) 17. FATHER'S NAME (First, M1ddM, Last) to MOTHER'S NAME (First. Middle, Maiden Surname) Charles Ward Namie o 19a. INFORMANT'S NAME fNpe/Pyrnr) 19b. MAILING ADDRESS (Shaer and Number or Rural Route Number, City or Town, State, Zip Code). D3 44 2 8 orothy, E. MacMillan 8700 W. Candleglow St Crystal River, FL 20a. METHOD OF DISPOSITION 20b. PLACE OF DISPOSITION (Name of canNflry, cretn pr or 20c. LOCATION - City or Town, State y Burial ?Cremataon O Removal from State odxrplace) QDonation pDthe<(Specify) Clearwater Cemetery Clearwater, FL Zia. SIGNATURE OF FUNERAL SE LICENSEE OR 21b. LICENSENUMBER 21c.NAMEANDADDRESS OFFACILITY PERSON 1 SU (of Licensee) Moss-Feaster Funeral Home /,'0Z_. 882 1. It. Harrisea Clearrater, F6 34615 Z 22a. T e eft yknowledge oath occuffed attha time..dwo all p e i7ue Q 239. On the lows of examination afidlbt imaestigation, in my opinion death occurred at Title . the time, date and place and due to the cause(d) and manner as stated. ure and THN A 22b. DATE SIGNED (Mo, DW Y) 22c. HOUR OF DEATH W 23b. DATE SIGNED pale. Day, N) 23c. HOUR OF DEATH c5 - - 3 8:40 AM M B11 22d. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or PrhV S6 23d. PRONOLINCEO DEAD (Mo, Day, W) 23e. PRONOUNCED DEAD (Hour) 24 NAME AND ADDRESS OF CERT M a. IFIER (PHYSICIAN; MEDICAL EXAMINER) (lype or Prier) Samuel R_ Miller, M.D., 206 N.E. Third St., Crystal River, FL 34429 SUBREGISTRAR SI TURE AND DATE 25b..LOCAI EGISTRAR - SIGNATURE 25c. DATE REGISTEREE 1993 ? ? p ? 28 PART I Ertfar the diseases. m)uriea or comp s thM Cal the loath: to not enter only the modo of dying, such as cardiac or re rat or heart failure, List only one cause each fine. sW Ny arrest, s is lmena Bdhveen nset and IMMEDIATE CAUSE (final Death I disease or condition ? : C*4-^ / r f 0 reaulong in death) -?` DUE TO (OR AS A CONSEQUENCE r " Sequentially list conditions, arty, rty, leading to immediate b. 01 if cause Enter UNDERLYING CRUSE (Disease or injury DUE TO (OR AS A QtIENCE OF): n? the! initiated events resulting in death) LAST C DUE TO (OR AS A CONSEOUENCE OF): ' l PART 11. Other aignificam conditions corwnbuting to death but not resulting in the 27a. WAS AN AUTOPSY 27b. WERE AUTOPSY FINDINGS 28. CASE REPORTE underlYing cause given in Part 1 PERFORMED? USED TO COMPLETE TO MEDICAL .?I , rVtJ?? .R ..r (Yes or No) CAUSE OF DEATH? (Yes or No) EXAMINER? M /r R"S ' ' /Jnff t.Lr ew FMP • No (Yes or No) 29 IF FEMALE; WAS THERE A 30a IF SURGERY 1S MENTIONEDiN PART I of It ENTER CONDITION FOR WHICH IT WAS PERFORMED PREGNANCY IN THE PAST 30b DATE OF SURGERY (MO.. Day, Year) 3 MONTHS? O YES (3XqO 31, PROBABLE MANNER OF 32a. DATE OF INJURY DEATH (Sped 32b. TIME OF 32c. INJURY AT WORK? 32d. DESCRIBE HOW INJURY ry,): Natural, (Month, Day; *Sf) INJURY (Yes or No) OCCURRED accident. suicide, homicide,.. or undetermined: / Iv n 32e. PLACE OF INJURY (?ihome; farm, 321. LOCATION street , factory, etc. (Street and Number or Rural Route Number, City or Town, State) K 512, dade4. lilion) COPY OF THE OFFICIAL RECORD ON FILE IN THIS OFFICE 1 OLIVER H. BOORDE BY State Registrar ANY OF THIS DOCUMENT LA NOT ACCEPT WARNING: UNL SS OONDSECUR)ITYY PAPER WITH INESS NDOSECURIITYYYWATE MOARKK ON BACK AND COLORED BACKGROUND AND GOLD EMBOSSED GREAT SEAL OF THE STATE OF • 3 0 FLORIDA ON FRONT. ALTERATION OR ERASURE VOIDS THIS CERTIFICATION. HRS.FORM 1564A 17-91) oernnrMrusroFnrlxY 8657 ,. RFl1ABIlJT.1TTVE_5FAVKA r ` __• 01 rya -% r+ ,