Chauncey, Robert and Dorothy
498
!
CEMETERY DEED
TIllS INDENTURE, Made this 9 t h day of SeD t em be r A. D., 1912.L between the City of
Clearwater, Florida, a municipal corporation created and existing under the laws of the State of Florida, party of the first
part, and Rob e r tan d Do rot h y C h a u n c e y
whose mailing address is: 1530 S. Greemvood Avenue, C1ear~!ater, Florida 33516
. of the County of Pin e 11 a s
, State of F lor i d a
, part i e S of the second part;
WIT N E SSE T H: That the said party of the first part, for and in consideration of the sum of $ 3 4 0 . 0 0
, to it in hand paid by the said part i e s of the second part, the receipt
whereof is hereby acknowledged, has, remised, released, and quit-claimed, unto the said parti ~ of the second part,
and the i r heirs forever, all the right, title and interest, which the said party of the first part has in and to the following
described parcel of land, lying and being in Pinellas County, State of Florida to wit: Space seE, D
Lot
24
Block 1 5
Florida.
Clearwater Cemetery, as recorded in Plat Book 60
Page
30
Public Records of Pinellas County,
This conveyance is subject to the condition that Grantee herein shall not assign or convey said property without the
written consent of the Grantor, and to the further condition that said property shall be 'used only for cemetery purposes as
human burial sites and is also subject to such other rules and regulations the City of Clearwater may adopt pertaining
to use of said described property.
TO HAVE. AND TO HOLD the same to the only proper use, benefit, and behoof of the said part i e s
of the'second
part the i r heirs and assigns forever.
IN WITNESS WHEREOF, said City of Clearwater, a municipal corporation, 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 its City
Clerk on this the day and year first above written.
Signed, Sealed and Delivered
in the presence of .us:
C;V~'A~' j0t~~rl ~
I 6r
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~./'.A . ro.. <t.... ed....as.t. o. fQrnt\an. d.. correctness:
/P/~ /.,', //) ~.
// 1 ~ji it /1~ ~.) :,.'! /.- *s-, '.-. City Attorney
/ State of Florida,
.~ County of Pinellas:
Attest: {J
~~
L ~. #. _
,.."J
City Clerk.
Personally appeared before me
Charles F. Le Cher, Anthony L. Shoemaker,
Lucille Williams
and to me well known to be the persons who
executed the foregoing instrument of conveyance in the capacity of Mayor Commissioner, City Manager, City Clerk
respectively, and they severally acknowledged that they executed said instrument in their respective capacity by and
on behalf of and as the free act and deed of the City of Clearwater, Florida, a municipal corporation, for the uses and
purposes therein expressed.
Witness my hand and official seal at Clearwater,
September
A.D. 198~.
day of
(Seal)
This instrument was prepared by:
Notar:.~ Pup ":0 te of Florida.
- Notary Pub~, 5~a~;of Florida
My Commission expires My Ccmm;$~i(1n Expires July 5, 1985
aoh~~~ 1 :~fU Tfo'r 1i.J!ln . !n;01.irs,1\:.:I, Jne.
Thomas A. Bustin, City Attorney
City of Clearwater, P. O. Box 4i48
Clearwater, Florida 33518
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STATE OF FLORIDA
OR.e.MvJ InfJ2.. (' e-,~C3
I ( ). - 0c 05 ceo I~ .
aLartAiKl'i..rl ( F(A .") ")S-l-b
A1r(~'; CtikflErzy [)IV.
Dear Sirs:
F~:~. r, -. ..~":,...
I~~f".\ U \-- ;_.,J i
DEPARTMENT OF
Health & Rehabilitative Services
. .
Bob Graham: 'Governor" .-
District Five 893-2700
8770 - 49th Street North
Pinellas Park FL 33565
~'fp.~ f!R: 11 \,Tl I ;-~ I [\
'..IJi~ \.~!i;l! ~l Jr.... It. i
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MAR 2 1981
PARKS !>.ND R::CHEATIJN
RE: J~ r:S C/fA-uNC7
1 i1g I
The above mentioned individual has applied for
nursing home assistance with the State of Florida. In
order to determine this individuals eligibility for this
assistance we must have the following information
concerning the i r burial plo t (s) .
v::
1. A.
A.
~.
~ ~.
~E.
0.
J
II. A.
/
../B .
Legal Description of Plot(s)
Name of Deed (Ownwer)
How
C..;.b
Are
How
l.
2.
3.
How
I.
2 .
3 .
many spaces owned by client and
:J.-
these plots saleable? YES------1-
many are occupied?
Spaces ,
Crypts
Vaults
NO ---l
~ Current Mark,'lt 2a~ue #/ 0 E k
of e a c h : .,. \\ E- ( .t' A- I ]) 0 Itc.
$ C. u.. r<. f!.-E JJT 1-. V 0 rJL Y ;l.. -4 iJu.. L. T J"~
$/fIfE Lc:,FT HJ Be SoL./) /,iJ
$ 13~cJ( /{L - TI! eY ,4,L:.E- ~7tJ /A-C-)I
JI c./Ty ;('Ej/u12cAlf--Jc...s - "8.s- ONLy
Any headstones, plaques, monuments or other markers. ./ EIk-'H
which are not inscribed on clients plots YES___ NO ~.
What is current market value of all uninscribed
markers $
many are
Spaces
Crypts
Vaults
unoccupied?
I
Please try to respond to this inquiry within 10 days
as we cannot determine eligibility without this information.
.
Your coo~eration 'in this matter is greatly appreciated.
f1~ A?Js~G-1l- !+tt-
't tJ J ~ D J Lrofll..1 .
~Oc)l
Sincerely,
~v,;srfoN5
fh~ {t::.-
C A~()L l<opsCo U-~-
PUBLIC ASSISTANCE ELIGIBILITY
SPECIALIST
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eee
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CLEARWATFR/r:ONVALESCENT CENTE~
Ino TlJRNFR STREET. r'\ rAf1WAlfn II ()HII1A :l:1'ilf. . lfil11 ,uJi6:l~
" -
AUTHORlZATIOM TO RELEASE INFORMATION
I certify that the information given by me in applying for
payment under Title XVIII of the Social security Act is correct
I authorize any hplder of medical or other informatlon about me
to release to the Social Security Administration or its int.....
mediaries or carriers any information n.e(l!oP<'l for thi. or a
related Medicare claimo I request that paynant of authori~~
benefits be made on my behalfo
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a1:1en1: of e. p Bible party
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CLEARWATER CONVALESCENT CENTER
1270 TURNER STREET. CLEARWATER FLORIDA 33516 . (813) 443-;639
t.PR 7, /9&/1
!~rr\
April 2, 1980
Clearwater Cemetary
P.O. Box 4748
Clearwater, Florida
Dear Sir:
Mr. James Chauncy is applying for Medicaid assistance.
In order to do this we need the following information
on him.
II J (, l' t (t Ci
On his two cemetary lots valued at ~'each at time
of purchase we need the value of each lot at the end of
November 1980
December 1980
January 1981
Yvonne Har ick
Administrator
YH/jh
..........-......................................................................................................................................................................................
3-13-02; 12;34PM;CITY CLERK DEPT.
;727 562 4086
# 21 2
k
March 14, 2002
AFFIDAVIT
I, Dorothy Vanderau, daughter, do hereby attest that I am the
surviving heir of Arthur F Chancey, deceased, who Is the owner of Lot 54,
Block 9, Spaces 1 through 4 in the Clearwater Municipal Cemetery.
Please take this affidavit as authority to grant interment rights for
Dorothy Vanderau in Space 3.
I
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 the above descendants.
..
SIGNA TUREI
RELA TrONSHIP TO DECEASED
~6/7~V~
orothy V erau ~
ADDRESS/PHONE
(f~v~~~ by,
3 7>.5
SWORN TQ af}d supscribed before me this ~ day of March, 2002
o 1'1' VlflfVdt'f'I who is personally known to me.
I
ature (Printed Name)
......~".,'.. JAMES J KlAUSCH II
~~~....~.\ MY COMMissiON # CC 835514 If
~'.. . ..~j EXPIRES: Ssplsmber ti, ,:UU,; ~
...ll;p'f.~.'" Bonded Thru Notary Public Underwntar. ~
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................... 3':";'1' :':()2.';" 3 ~'5'5PM; 'C'I'TY" CLE'R'K" DE.pi:..........................................................; '7"2.7' '5'62' .4.086............. .t;..."2.I..."2".......
March 11, 2002
AFFIDAVIT
I, Dorothy M Varderau, is the daughter of Arthur F Chancey who is the owner of
Block 9, Lot 54, Space 2 in the Clearwater Municipal Cemetery.
Please take this affidavit as your authority to inter the remains of CORA SIMS
who is the widow of Arthur F Chancey, in Block 9, Lot 54, Space 2.
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 CORA SIMS.
SIGNATURE!
~LATIONSHIP TO DECEASED
~~Lbd~
, orothy M Von u
ADDRESS/PHONE
I if 22... ~~(}yooL b r .
(" [Pd.VW ~Q.v ~ (.
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and pubscribed before me this /..3 day of March, 2002, by
d~ who is personally known to me.
tureJ(Printed name)
.~\-:r.~'fit;:< . JAMES J. KLAUSCH
h I'~'}*~ M.'l' COMMISSION /I CC 835514
~~~~~ tXPIRES: September 5,2003
, ",'!fun-::-\ Bonded Thru Notary Public Underwriters
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