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Coulston, Donald January 20, 1994 A FFID A VIT STATE OF FLORIDA) COUNTY OF PINELLAS ) I, the undersigned, do hereby attest that I am the decendant, sole survivor and heir of Omay F. Blanton, deceased, who is buried in Block 8, Lot 57, Space 4, in the Clearwater Municipal Cemetery. I am heir to all real property, including cemetery property. (see copy of will attached) Please take this affidavit as your authority to inter the cremated remains of Donald Coulston, deceased, my husband, in Space 3, Lot 57, Block 8 in which my father, Grover C. Blanton is interred. I, the undersigned, wish to inform the City of Clearwater Municipal Cemetery to place my cremated remains in space 4, Lot 57, Block 8 with my mother, Omay F. Blanton upon my death. 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 either interment. SIGNATURE '~~J~ (? ~n Doris Coulston 105 N. Lake Drive, Clearwater, FL 34615 WITNESSES: SIGNATURES Wertvu ~ j de jJ~ UJoann F. Dunlap 3937 14th Ave. S. E., Largo, FL 34641 LD~ }y\n\()~~ Camille Motley 1140 ldlewild Drive S., Dunedin, Fl 3 8 RELATIONSHIP TO DECEASED ~rf/N~)@J /1tA)~ re furegoinjl instrument was ~CIrnOWledged before me thisda- ~ay of fk.,.H1 . fAd-- , , ort'S (I0f.,(L-S-C On {-JOa/711 L{n ~ who produced identificati~ rL4h-,ilers Llc..EAJ-s€," and who did/did not take an oath. 199j, by form of ~ ' )n.~ . ..110...., ary Publ~C~~'''''X~f~:._, . HOllY M. AUSA/JIO ~:.J~t}~J. W COI.t\~:~!GII.I,' CCZG9212 EXPIRES '~;;;S~i:.~;' . ',pril' 21J.1997 . . I""", :'. .,0 ~ O"''Jro..... -.......::; T~O'{ F.~m !:JSURANCE, INC, My commISSIOn expIres: . (SEAL) . I 105 LAKE DR.- CLEARWATER. FLORIDA 34615 2Oll. PLACE OF DISPOSITION (HelM oI~, ~.""'l' or 2Oc:. LOCATION - Clly 01 Town, Sial. 0/"" pIac.1 southeastern Cremator Clearwater, Florida 21b. LICENSE NUMBER 21C. NAME AND ADDRESS OF FACILITY (01 LIe......1 . t '~ >",. ~~~ . ..~.>: National Cremation society ~~ 4945 E. Sa Dr.- Clearwater Florida. 346m cr.. 23... On tM _ ol......in.toon .ndIOI,......ovabon, III my 0Il'1llOl'l delln OCQlIfed II ~ ~ - 1M lime, daI. end plac. end due 10 t/le cauH(,land man_ u ~. " U s u........ Tltle ~ ! ~gnrE fMGNED (M4.~ ~I .f~ri~ e2~;MEDIC1\LEXAMINER CASE NUMBER ~l ,2~ _ - _____ I 7747#31 ~ 0nMc and I~ Dealn Il ----I :,::~.>:~~.,~, ~~. ~~l;-, ~"'j,' $.... $~\ @\~; ~. I~ ~;.I ~; ;f;~\ ~~~ it\ i~, Il ~~, @{ ~.' ' ~ I:' r~L( I".:' ,~l: ~".,,_,t~q C:~l,l~.,i i.'INELI',\.; 0;:): '" i'. r L(;~;J'\ --.. _._~-_._---_.---_.-_.,------ .... ...-........-:r..... urRUC'-- r~~ FEB 9 JM THE CIRCUIT COURT FOR PINELLAS COUNTY, FLO 12. 14 PM . ~ f . ',R f COR 0 E b PROBATE DIVISION NO. 87-660-3E . ~.. iEB041987 IN RE: THE ESTATE OF Deceased. / tc\~UfiN F. [>::> ~l,l,~nt OIRl< ORCUiT \:,:~',mr ,roMTf Dr,,;s,'e;.,/ ~D:pI.ltl (..lt~ m" y.-- ;>,). . .....:~I - ~~;~ f') >- ? rl -1.~ ;.1:. ('to' ;T1 ~ =1- ., n --' ' ~r', ~ ,-" r- l-. It., f" 4.11 fJ ~ =.!' t V1 ...:-..... ~, I .. ,; "... __-... -u < -<1' ~ :C. COU~6N, ~S~ OMAY F. BLANTON, 01 C<1!.:'1 .: '. 0 ORDER OF SUMMARY l\DMINISTRATION 40 RccqJ?---- (testate) 41 OS -'---- 43 Int - - .- e-no-zr.J- Tot-f-V_v_~~ On the Petition of DON COULSTON and DORIS wife, for Summary Administration of the Estate of OMAY F. BLANTON, deceased, the Court finding that the decedent died on the 24th day of October, 1985, that all interested persons have been served proper notice of this Hearing, or have waived notice thereof; that the material allegations of the Petition are true; that the Will bearing date of June 17, 1970, has been admitted to Probate by Order of this Court as and for the Last Will of the decedent; and that an Order of Summary Administration should be 14 lQS7tf1G2"12 '19 ,~ TOTAL: :~. ADJUDGED, that there be immediate distribution of the entered, it is 1 . O~FF 1.99 9.09 Cf-: assets of the decedent as follows: DON COULSTON and DORIS COULSTON, his wife, 105 Lake Drive North, Clearwater, Florida, 33515, are entitled to and shall receive decedent's entire one-third (1/3) undivided interest in the unpaid balance of that certain Mortgage and Note recorded in OR Book 4788, Page 554, public Records of Pinellas County, Florida, dated 12 December 1978, whereby JUDGE ..- . -. ". CONSTRUCTION, INC., is the Hortgagor and Ol-1AY F. BLAN'l'ON, DON COULSTON and DORIS COULSTON are Mortgagees, which one-third (1/3) interest approximated $12,524.68 plus interest as of the date of her demise. ADJUDGED FURTHER, that those to whom specified parts of the decedent's estate are assigned by this Order shall be RETURN TO: C. tv .1,/t.)GILxIJ/fYf-'// .sor $. ,7,. ~!' lOt ,,:-)/1 ::.~ I -1- " '!' ;.1U....___.~ receive and collect the ....;~~!.~~~, ,~A~::;.:i,),,~S:L~: ."\;."L':"''''!~ ~' " I