Barron, Elizabeth Dillard
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July 3, 1997
AFFIDAVIT
STATE OF FLORIDA
COUNTY OF
WE, the undersigned, do hereby attest that we are the
descendant and heirs of the DILLARD FAMILY. Albert N. Dillard,
sole surviving
deceased, and
his wife Elsie Hart Dillard, deceased, are buried in Block Five (5), Lot Twenty
(20), Spaces Four (4) and Five (5) respectively, in Clearwater Cemetery. Also
interred is their daughter, Isabel Dillard Whatley in Space Six (6); their
parents Elizabeth N. Dillard in Space Three (3) and S. N. Dillard in Space Two
(2) and Mary A Dillard in Space One (1) (not certain of the relationship) .
I glVe-p-errtllss'rOIt Lv .LuL<::.J.. the Q:660m.atooccJ::e.rr''''; nl'l nL. ELIZABqH DILI.ARJ:)
BARRON, deceased daughter of Albert N. and Elsie Hart Dillard, in space Seven
(7), Lot Twenty (20), Block Six (6) at Clearwater Cemetery.
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 of ELIZABETH DILLARD BARRON.
"- ~-~~."""~
(son of Elizabeth Dillard Barron)
WITNESSES:
SIGNATURE
RELATIONSHIP
(SEAL)
me on this tl~ day
County, State 0 Florlda.
~ -ShtM d-:J H. 9~
Notary
M~I C~ZiSS~ ~pires:
of
SWORN TO AND SUBSCRIBED before
/0 +A , 1997, inJ:LfbcL
'.I,
July 3, 1997
AFFIDAVIT
STATE OF FLORIDA
COUNTY OF V':<l.Lllo-S
WE, the undersigned, do hereby attest that we are the sole surviving
descendant and heirs of the DILLARD FAMILY. Albert N. Dillard, deceased, and
his wife Elsie Hart Dillard, deceased, are buried in Block Five (5), Lot Twenty
(20), Spaces Four (4) and Five (5) respectively, in Clearwater Cemetery. Also
interred is their daughter, Isabel Dillard Whatley in Space Six (6); their
parents Elizabeth N. Dillard in Space Three (3) and S. N. Dillard in Space Two
-----t2f--and" Mary--A- Dil'tarcr-irrspaceOrre (l-t tnut-Tertain of' then relatIUITshTp). ,,,-__~,,OC ~--
I give permission to inter the cremated remains of
ELIZABETH DILLARD
BARRON, deceased daughter of Albert N. and Elsie Hart Dillard, in space Seven
(7), Lot Twenty (20), Block Six (6) at Clearwater Cemetery.
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 of ELIZABETH DILLARD BARRON.
red C. Bolton
1623 Sandstone
Clearwater, FL
of Elizabeth Dillard Barron)
WITNESSES:
SIGNATURE
RELATIONSHIP
~~~
L/g~ _~ < -~
of
SWORN
-rll\~
\fL ~k -ti B<..{~$." ~Cf~.3d-Y("'I-()
TO AND SUBSCRIBED before me on this I I day
, 1997, in P: i'l.R I(a.s County, State of Florida.
'-8 () Q a.J1fF.I".1,
Nota y
My commission expires:
(SEAL)
ELLEN Y. SPINK
MY COMMISSION (J CC 817267
:~< EXPIRES: JanIlllY 29. 2001
,f;lrt..~ BandIId Thru Notary Public UndelWlllll8
.
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SEPTEMBER. 29.1913 .,'. ,.i ...,. '.,. : CLEARWATER. FLORIDA ...., '" '". '.., .' .',... '..... (>CT',YES ";-\ ...... T'f
9,f,PLACS OF OEATH(C~ lltlIy elM s.uiSInJcDo/l$ 011 ....., side) .,'.. ' ..". .'.. '. ., in "...." . .'..", ..'" ....".,..... .... ...9b INSiDe ~ITY H"-lITS? (lits\ t-JO)n
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'38 INSIOE CITYv"';. f'331I";ZI~CODE. ,.,..'.. . .14 WAS DECEDENT OF HISPANIC OR HAITIAN ORIGIN? ,', ',15 RACE - Amet/can Ind,.n, 160ECEDENT'S EDUCATION;_~cL2." ,.
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-17 FATHER'S~~ME (FIrst, M'C/d/e, ~st) ......."... ,'.'.' "..,,'. ..' . '.. ...',',. 1'6 MOTHER'S NAME (F,rst, M'ddle, Ma'l1enSumam.). .....,..".,..."...'... ,'" .
"ALBER'I'~~nILLARD '.' ,', .,'...,. .....,.'.. "ELSIE HART"c:..'''' ..."Ji
.'9~ 1~~pF;lMANT~~~A~FlrypillPti7t)i ,..1 19b MAILING AODRESS(Stt8el and Number or RureiROuteNu/'!lber Ciry ot TownSt~llI, Zrp CO~)L ' ,..." .'
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"fOaMETHOOOFQfSPOSlTIONi ,..,'.',. 20b~LACE OF DISPOSITION lNarile 01 cemetery. cremalOly. 0l,2OC LOCATION - C.lyor Tciw[".n"r! Stat. '.....,........'...',... ,...,..' .....,""
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, .. 21a ~~~~TURI;!OFF(JNERAL gtAVICE LICENSEE OR 21b LICENSE NUMeER' ,...' 21c NAME AND ADDRESS OF FI'Cl,LITY S.;.:S. ...'... ....,<\'.> "
P,i,ON ActING AS SUCt;l , (o/LlCenSH) MARIANNA CHAPEL FllNERALHOME ,..'..,.,.....'....'., ',,'>
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26 'PART I 'Enter l,he diSeases, 'Inlunes, or campllcallons I..... caused Ihe d.ath, 00 not enle'lh. moc:le 01 dy'ng. SuCh ~ cardl4<"or resporaf'ory ar'~\flocT;" p.'he." I APP(O~~~ In~ "..<
I." ,'fall,ure LISI only one Clluse on ucll IIn..... I ~I'J'OhSM and, .'..
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....,.< I," DUE TO (OR AS A CONSEOUENCE OF) >i< ..",.. ,.....'.".,.", .' , · '..,... '>/_&<:_,i
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.. PART II Oth.r 3lgn,hcant c.Qndlllon~.cj;nlil,b\llIn9 10 death ~ ,no' resull'nw.n lhe ... ,'.. 27a WAS AN AUTOPSY 27b. WERe AUTOPSV FINDINGS" '.... ,.' ' '.. '.26CASE' REPOATEO '
'.... und.rIY'n9CaUSeg'....n.IIJPay ~ .... PERFORM"D' USEOTOCOMPLETECAUSe'..'..'.'.. '>TOMEDIC'AL
> "(" D. (~S or No) OF DEATH? (Yes or No) I EXAMINER?
.'.............<2>'1..'-..1 IJI ,... , ".. ~m .'.., ,.."" 'i.i>> IJ~~ri~)> .'"i.
29 ,IF FEMAl-E, WAS THERE A ".30a, IF SURGERY IS IlENTlONED IN PAAT I 0' II ENTER CONQIT'ON FOIl WM'CH It WAS PEFlFQAt.lED ..'...I~3Ob DATEr OF, SURGERY 11010 l:l~l!ea').' '..,'
'PREGNANCY IN THE P.$ST ./.. i- '.' i.i....... "...
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>} ,.,',.'.,)< tHiS IS ~. ~~O'CORREC !COPYOF THEOfFtCIA~RECORD ONF'~E~~T~IS9f~t9f}i'
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Mr. John Dillard Barron
3953 Stallion Lane
Marianna, FL 32448
Dear Mr. Barron:
Enclosed is an AFFIDAVIT giving your permission to
inter the cremated remains of your mother, ELIZABETH
DILLARD IBARRON.
If the information is correct, please sign as
indicated below SIGNATURE and have two individuals
witness your signature in the presence of a Notary
Public. Then return the document to The City Clerk
Department, City of Clearwater, P. O. Box 4748,
Clearwater, FL 34618. When I receive both AFFIDAVITS
(one from you and one from Fred C. Bolton) and proof of
your mother's relationship (a death or wedding
certificate and a copy of the page in your family
bible) I will make the information part of our permanent
file.
When you are ready to place your mother's remains,
remember, you must have a funeral director request the
staking of the space for which there is a $30.00
charge. A funeral director must also oversee the
placement of your mother's cremated remains. This can
be done either by the funeral director who was in
charge of your mother I s funeral or a local funeral
director.
When you are ready to place your mother's military
marker you will need to contact a local monument dealer
to take care of the installation. Our caretaker will
give directions for the placement of the marker when
necessary.
If you need to contact me for any reason, please
call 562-4098. Thank you.
Camille Motley, Central Records Specialist
cm
Enc.
~Ad~Ooc!wY iJ~ ~-U~_
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CITY OF CLEARWATER
POST OFFICE Box 4748, CLEARWATER, FLORIDA 34618-4748
Cm' HALL, 112 SOlrrn OSCEOlA AVENUE, ClEARWATER, FLORJDA 34616
TELEPHONE (813) 462-6684 FAX (813) 462-6488
DEPARTMENT OF THE
CI1Y CLERK
July 3, 1997
Mr. Fred C. Bolton
11623 Sandstone Court
Clearwater, FL 34616
Dear Mr. Bolton:
Enclosed is an AFFIDAVIT giving your permission to
inter the cremated remains of your distant cousin,
ELIZABETH DILLARD BARRON. The information contained in
the body of the affidavit was given to me by Mr. John
Dillard Barron who is the son of the deceased.
If the information is correct, please sign as
indicated below SIGNATURE and have two individuals
wi tness your signature in the presence of a Notary
Public. Then return the document to The City Clerk
Department, City of Clearwater, P. O. Box 4748,
Clearwater, FL 34618. Mr. Barron will also execute a
similar document.
If you need to contact me for any reason, please
call 562-4098. Thank you.
Camille Motley,Central Records Specialist
cm
Enc.
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"EQl'Al E~lPLOYMENT A.'\O AFFI~"lATlVE ACTION E~lPLOYER"
,<
July 3, 1997
AFFIDAVIT
STATE OF FLORIDA
COUNTY OF
WE, the undersigned, do hereby attest that we are the sole surviving
descendant and heirs of the DILLARD FAMILY. Albert N. Dillard, deceased, and
his wife Elsie Hart Dillard, deceased, are buried in Block Five (5), Lot Twenty
(20), Spa~es Four (4) and Five (5) respectively, in Clearwater Cemetery. Also
interred is their daughter, Isabel Dillard Whatley in Space Six (6); their
parents Elizabeth N. Dillard in Space Three (3) and S. N. Dillard in Space Two
(2) and Mary A Dillard in Space One (1) (not certain of the relationship).
I give permission to inter the cremated remains of ELIZABETH DILLARD
BARRON, deceased daughter of Albert N. and Elsie Hart Dillard, in space Seven
(7), Lot Twenty (20), Block Six (6) at Clearwater Cemetery.
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 of ELIZABETH DILLARD BARRON.
SIGNATURE
Fred C. Bolton (cousin of Elizabeth Dillard Barron)
1623 Sandstone Court
Clearwater, FL 34616
WITNESSES:
SIGNATURE
RELATIONSHIP
SWORN TO AND SUBSCRIBED before me on this
day
of
, 1997, in
County, State of Florida.
Notary
My commission expires:
(SEAL)