Dierken, MargaretCemetery Call Work Sheet
• Date:/ / 1°1/ ?2.
Funeral Home / Monument Company: 1 `S 1`�C�.Y
Contact Name: �� \
Tel. #: CZ.13a " 2"li Fax #:
Email:
Reason for call:
** Staking Request — Interment
$30.00 staking fee (Weekdays) - $50.00 staking fee (Saturday, Sunday & Legal Holiday)
Full Burial Urn Burial
(One full burial and one urn, or two urns per space)
Owner of Plot: NtC 4'c2 ke-f l
Deceased Name: tt
Block 1S Lot IIS Space
Date of Birth: t2 127"/ 9-k Date of Death CP / 15 /
Date of Burial: 7 /71 / 7)' Time: am/pm
•**
•
_ Monument (Marker) being placed - (No fee for staking of monument)
For:
Block Lot Space Date: / / Time:
Affidavit (Burial Rights) Verifying Burial space
Other reason:
***********************************************************************************************
Send email to PSBR to stake the space
Y Notify funeral home/monument company with color of the flags used to mark the space
Staking fee received on: / / From:
Copy of permit emailed to:
Nathan Brigman, cc: Matt Anderson, Tim Chaplinsky, Erick Peterson in P&R on: / /
**************************************************************************************************
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
ORLS/Cemetery/FormsPermitsTemplates/Cemetery Call Work Sheet -20
Revised 4/21/2021
•
Cemetery Call Work Sheet
Date: Cs/ 19 / aa -
Funeral Home / Monument Company: esz,nrleir 6r1 cali O )
Contact Name: Tel. #: Fax #:
Email: tervPizz, `hQ4-IcQ‘C•C'C'Sn •1
Reason for call:
**
Staking Request — Interment
$30.00 staking fee (Weekdays) - $50.00 staking fee (Saturday, Sunday & Legal Holiday)
Full Burial Urn Burial
(One full burial and one urn, or two urns per space)
Owner of Plot: li
t c r
Deceased Name:
Block S. Lot lib'_ Space (IIV/< <'o/a— '
Date of Birth: / / Date of Death / /
Date of Burial: / / Time: am/pm
•**
•
Monument (Marker) being placed - (No fee for staking of monument)
For:
Block Lot Space
Affidavit (Burial Rights)
Other reason:Nikseedblir--tc2.
Date: / / Time:
Verifying Burial space
1fn %C1.k.)
w /!_
oma,
**************************************************************************************************
Send email to P&R to stake the space
Notify funeral home/monument company with color of the flags used to mark the space
Staking fee received on: / / From:
Copy of permit emailed to:
Nathan Brigman, cc: Matt Anderson, Tim Chaplinsky, Erick Peterson in P&R on: / /
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
ORLS/Cemetery/FormsPermitsTemplates/Cemetery Call Work Sheet -20
Revised 4/21/2021
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537
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CEMETERY DEED
O. i. 5608 f'},cE2195
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"-'! CLtK~. Clr,C'JI'T CUUKT
S[F ,2 4 38 PH 'B3
THIS INDENTURE, Made this 12th day of September A.D., 19~ 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
Margaret Dierken
whose mailing address is:
1417 Lime Street. Clearwater, Florida 33516
of the County of Pin e 11 as
, State of Florida
, part X-- 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 $ 2 0 0 . 0 0
, to it in hand paid by the said partY_ of the second part, the receipt
whereof is hereby acknowledged, has, remised, released, and quit-daimed, unto the said part ~ of the second part,
and her 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
C
Lot 11 5
Block 15 Clearwater Cemetery, as recorded in Plat Book 60
Florida.
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 Y
her
of the second
part
heirs and assigns forever.
Signed, Sealed and Delivered
in the presence of us:
8~~ By
~_. '7?1J.~
,-Li/;cA4L~ ,&~7t ~
A. pproved .as. to fonn andcorrectn/..ss.
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.. . to'- City Attorney
State of Florida,
County of Pinellas:
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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 seal1l!fixedby its City
Clerk on this the day and year first above written. . ,. '< '
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City Clerk.
Personally appeared before me Kathleen F. Kelly, Anthony L. Shoemaker
and L u c i 11 e Will i ams 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.
SE:>pTPmhpr
(Seal)
This instrument was prepared by:
A. D. 19.8..3....-.
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Witness my hand and official seal at Clearwater, Florida, this the
Thomas A. Bustin Cit
City of Clearwater, P. O. Box 4748
Clearwater, Florida 33518 40 Rec
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My Commission expires
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My COr.lmis~ic.n tx;:;rcs Od. 31. 1~g3
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