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Hannum, William H .... INST # 95-059164 ~MAN 15, 1995 4:20PM c CEMETERY DEED AND CONSENT TO CONVEYANCE JHIS INDENTURE is made this 2 3~ day of 0 ~~ ~tty-'" ' , 19i~ , between Estate of Af'.iy T. GUTHRIE (HAN~ - - ' .')1 and WILLIAM H. HANNUM, ~rsonal representative for the estate of Amy T. Guthrie) whose mailing address is 213 Arlington Avenue, Naperville, II 60565 of the County of WILL- , State of 1:-L'L-l'fJO\ S . , as Grantee: , PINELLAS COUNTY FLA OFF.REC.~F 8~37 PG 945 ., WITNESSETH: That the said Grantor transfers ownership to Grantee and has remised, released and quit claimed unto the said Grantee, and his 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: Space 3, Lot 47, 't :cBlock9, Cle~Hwater Cemetery, as recorded in Plat Book 60, Page 30, Public Records of Pinellas County, Florida. This Conveyance is subje.::t 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 f.or 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 his heirs and assigns forever. IN WITNESS WHEREOF, said Grantor has signed and sealed these presents on the day and year first above written. 11 RECORDING ACCT I 0007'0 n ./ A _ ~ _ '. C ;.0;. DE ~ (Grantor(s) address:) VVVt///~C ~\O-)O uthrie, f/k/a DF\2'19 (deceq$ed) __..___ DS c/o 213 Arlington Avenue William H. Hannum INT Naperville, IL 60565 (name type/printHPersonal RepresentatiJ~~!stftt-et--- t I " (Witness (2) Signed, Sealed and De/iverlfEES 0 (Witness) names and addresses) m t~enc~ qJ., us:) iJ MTF ~ '1_,. . 0 _ ':::::1-.l4JU. ~ . ~~O dJ~ C(lfJ!J S. (l,~ Cwf ~i?~)utJ! tIIl8zml 0 (0 q 100 S. ~ ~ 11" A'~-.J--.C1 i, tJ? (pol..{ <':'>'1 (name type/print}:),?tf ( ~. , STATE OF IL. COUNTY OF (!,() OJc.." ) } v ....;..- ' RETURN TO: CITY CLERK POST OFFICE BOX 4748 .CLEARWATER, FL 34618-4748 OFFICIAL SEAL SUSAN A. TEPPER NOTARY PUBLIC. STATE OF ILLINOIS MY COMMISSION EXPIRES 5-17-98 Acknowledged before me on this d3~day of u , 199~ by who personally known to me or has produced ..J.'- JJI2I JGfe-.,j L-/( . ,-as identification and who did take an oath. 1~) Cl. ~UbliC Print/type name: ~S,4-1.J 11. TE f/fJ'6-fL Page 1 of 2 CONSENT TO CONVEYANCE PiNELLAS COUNTY FLA. OFF.RE~.BK 8937 PG 946 , , .. The City of Clearwater, Florida, a municipal corporation, hereby consents to the conveyance of Space 3, Lot 47, Block 9, Clearwater Cemetery, from the Estate of Amy T. Guthrie (Hannum) the Grantor to William H. Hannum, 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. ITY OF CLEARWATER, FLORIDA By: ~~~ Elizabeth D ula, Cit Manager Approved as to form and legal sUfficiency: Y/2p.? ,~ Paul Richard Hull, Assistant City Attorney Attest: Susan Stephenson, Depu '\ I I I STATE OF FLORIDA ) COUNTY OF PINELLAS) Before me, the undersigned, personally appeared Rita Garvey, the Mayor-Commissioner of the City of Clearwater, Florida, who executed the foregoing instrument and acknowledged the execution thereof to be her free act and deed for the use and purposes herein set forth, and who is personally known to me. WITNESS my hand and official seal this3 f\..-J..-day of ~, 199.l~ Ca~ >~ ~-,--'d J (SEAL) 0 Notary Public Print/type name: CAROLYN L. BRINK Nul"",)' l"ublk, 5laLe or b'lorlda My comm. expires May 22, 1994 Comm. No. CC 111741 STATE OF FLORIDA ) COUNTY OF PINELLAS) SEAL) Before me, the undersigned, personally appeared Elizabeth M. Deptula, the Interim City Manager of the City of Clearwater, Florida, who executed the foregoing instrument and acknowledged the execution thereof to be her free act and deed for the use and purposes herein set forth, and who is personally known to me. WITNESS my hand and official seal this 3"';" day of ~ ,199/ 5' C ~~ ~ Notary Public Print/type name: CAROLYN t. BRINK ~ul<1l-Y .t-'UbllC" State of Florida Y COInm. explres May 22, 199.5 Conun. No. CC 111741 Page 2 of 2 INST # 95-059165 " MAR 15, 1995 4:20PM CE;METERY DEED AND CONSENT TO CONVEYANCE THIS INDENTURE is made this 23,tl day af n Ay\.!^ ArVl -' 191(,qetvvean Estate of AMY T'IlGUTHRIE (HANN~M) as Grantar and WILLIAM H. HANNUM, persanal representative far the estate af Amy T. Guthrie) whase mailing address is 213 Arlingtan Avenue, Naperville, II 60565 af the Caunty af _W} 1- Lo v State af ):\..,1..\ tJ'o \ S ' , as Grantee: . . PINELLAS COUNTY FLA. OFF.REC.BK 8937 PG 947 WITNESSETH: That the said Grantar transfers awnership to. Grantee and has remised, released and quit claimed unto. the said Grantee, and his heirs farever, all the right, title and interest which the said Grantar has in and to. the fallawing described parcel af land, lying and Qeingin Pinellas Caunty, State af Flarida, to. wit: Sp~ce 4, Lot 47,; a.t;oek .9, Clearwater Cemetery, as recorded in Plat Book 60, Page 30, Public Recards af Pinellas County, Flarida. This Canveyance is subject to. the candition that Grantee heroin shall nat assign or canvey said praperty with aut the written cansent af the City af Clearwater, Flarida, and to. the further canditian that said praperty shall be used anly far cemetery purpases as human burial sites, and is subject to. such ather regulatians the City af Clearwater may adopt pertaining to. use af said praperty. TO HAVE AND TO HOLD the same to. the anly praper use, benefit, and beho.af af the said Grantee ;and his heirs and assigns farever. IN WITNESS WHEREOF, said GrantQf has.si~p~d and sealed these presents an the day and year first abave written. 11 FlECOHUI ,1) ACCT I (l001 ~ CODE CI~;:) (Gra t r( ) n REC , O. ~ ~ DR21g Estate af Amy T. Guthrie, a/k/ Cbs Amy T. Hannum LNT .; William H. Hannum P/r. (name type/printHPerso.nal Represent~Taf Estate) (Grantor(s) address:) deceased. __. __ . c/o 213 Arlington Avenue Npaerville, IL 60565 "\1'1, ,jl'-' RETURN TO: CITY CLERK POST O\"'::!;~:- Grrl 4748 .CLEARVVAL.h, fL 3':-::'8-4748 , 199.6;by who. persanally kno.wn to. as identificatio.n and who. did take an aath. .J. /1. ) 4.~ f. 1.-1 /"')/ '~Iic Print/type name: Su$1hJ ~, /E,,tJPGrc- Page 1 af 2 ~ PINELLAS COUNTY FLA. OFF.REC.aK 8S37 PG 948 CONSENT TO CONVEYANCE The City of Clearwater, Florida, a municipal corporation, hereby consents to the conveyance of Space 4, Lot 47, Block 9, Clearwater Cemetery, from the Estate of Amy T. Guthrie (Hannum) the Grantor to William H. Hannum, 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. ITY OF CLEARWATER, FLORIDA By: Elizabeth D ""\""1'1/(1"1 .,.:~ \' ~ ~ ." : I, , City Man~gl:lr ",;.., ... ."', . .... '., .. . ~. Approved as to form and legal sufficiency: M/&.~ - Paul Richard Hull, Assistant City Attorney Attest: Susan Stephenson, Deputy C' ~ Clerk" ,: ", '. ....~.o:" c()' ..~. ~, I; \ ,~,,~ . ~ f", ., ,\ , . , C" r ' I'll. STATE OF FLORIDA ) COUNTY OF PINELLAS) Before me, the undersigned, personally appeared Rita Garvey, the Mayor-Commissioner of the City of Clearwater, Florida, who executed the foregoing instrument and acknowledged the execution thereof to be her free act and deed for the use and purposes herein set forth, and who is personally known to me. w... ~.. I~.A~ S WITNESS my hand and official seal this J 7 day of ~-~-~ - U ' 199/ . C~~~ (SEAL) CARot YN t. BRINK Notary Public Print/type name: Notary Public. State of Florida My carom. expires May 22, 1911a Comm. No. CC 111741 STATE OF FLORIDA ) COUNTY OF PINELLAS) Before me, the undersigned, personally appeared Elizabeth M. Deptula, the Interim City Manager of the City of Clearwater, Florida, who executed the foregoing instrument and acknowledged the execution thereof to be her free act and deed for the use and purposes herein set forth, and who is personally known to me. . U- WITNESS my hand and official seal this ~7 day of SEAL) d~~?/ ,199! s. C~ ~of.~ CAROeYN l. BRINK Notary Public Print/type name: Notarv Public. State of Florida My comm. expires May 22, 1995 Comm. No. CC 111741 Page 2 of 2 ?~ .' 11) / '0../ ---, I to Iv /6-0' , ,~', ~4' form S l-i I\\orida l"l1otolltAt TUTBLAhX RE.GISTERED us FAT OFFICE f--.lt. . .\. 'Tuffle Law Prmt PU.bIt5h",rs. RullandYl "'r-I 4'~ .( q- i - Inbtnlurt O.R. 1b 't;[ 482 day of ~ June A. D. 19 57 H. HANNUM, widow and sole heir of WILLIM'I E. died October 29, 1956, at Clearwater, Florida, QUIT CLAIM DEED. , . . t11 Made this Between ANN BEL HA~1, deceased, who of Weirsdale, and Marion and State of Flor idV ROBERT H. HANNUH and Arty T~ HANNUN, his , (of the County of , part y ofthefirst part, wife, of Weirsdale, , of the County of ~arion ; and State of Florida , part ies of the second part, WItnesseth., That the said part of the first part, for and in consideration of the sum of Ten ($10.00) ----------------------------~-------Dollars, in hand paid by the said parties of the second part, the receipt whereof is hereby acknowledged, ha s remised, released and quit-claim.ed, and by these presents do es re7nise, release and quitclaim unto the said part ies of th.e second part, and their heirs and assigns forever, all the right, title, interest, claim and demand which the sq.id part y of the first part ha s in and to the following described lot ,piece or parcel of land, situate lying and being in the County of Pinellas State of Florida, to wit: v y:" Lot Forty-seven (47), Block Nine (9), Clearwater Cemetery To Have and to Hold the same, together with all and singular the appurtenances thereunto belonging or in anywise appertaining, and all the estate, right, title, interest and clailn whatsoever of the said party of the first part, either in law or equity, to the only proper use, benefit and behoof of the said parties of the second part, their heirs and assigns forever. In Witness Whereof.,. the said part y of the first part ha~s hereunto set .her . hand and seal the day and year first a~Jf writte Signed, Sealed an~ Delivered in ~re8ence of: t4 ~ 4J.I~.1 X 1M <<~rYL~' '. L 'I Ii " ~ . . e '~ /J .".<,~ I IF.. ,oJF",""" ," ~ a ~~~,~ t. ~v / I 1-1 C. 50 S ~ ..-) ~tate of Florida., } 'County of Marion I HEREBY CERTIFY, That on this day personally appeared before me, an officer duly authorized to administer oaths and take acknowledgments, ANNABEL M. HANNUM, a widow, unmarried, to me well known to be the person described in and who executed the foregoing instrument and she acknowledged before" me that she executed the same freely and vo.luntarily f~o pur, oses ther~n .J;xl!ressed. . - WITNESS my hand. .ayylofficial seal at . . (~~L.z:&.--, County of 14o.rion ~ , and Sta e 0 orid' this / ~ day of June ~ A. D. 19 57 . r :7' " 1957 0.N ~~ /;N 11: 15 . 4 Pa.-u -' ~,'ll ~"z., ]V, ary Pubhc - state ofYl ,'ida, a,.t '.11 r, y Commission Expires y~ ~-~9C?,f\ ;: ;-r t /r <q\ t"': :~'..- ."y . f' ", 1 0 r ' 6 I~ f' ,f' .. (" .. " \ " u \., ' RECORDED PINElLAS CO FlA AVERY W. GILKERSON. ci.'ERI{. ,.;g::gf!ii,Ii1l~:Jt::;j:z-:. Sp j" ~, ~ -' ~ I : I 'f ) ) /, 11 \' g a p:: . -~ ~~ ri (l) .0 m @ ~ ~ .j..) (l) o ~ ~ m ~ . :Il .j..) H (l) .0 o pc; ~ II~ r- U\ 0" ri ~ -< ~ .... i ~ ~ o ~ ~c.o.. -< 0 ~C> oo~ 8 (l) g ~...... eo ~ Il:> I Il:> Il:> -..;, . .,." '"' ~ Il:> ~ Il:> ~ ~'~ ~ ~ ~ Il:> 'esi~ /0.., -..;, -..;, ;::s ~ ;.,;)r:::li::lr:::l Il:> <::>.... eo 0 ~ ~ ~ ~ ....... ,:; ;::s =-~ /0.., ..... Il:> 0 c:.s ~C2 ~ /0.., ~ ~ ~Il:> ~ ......., o~ 0 -..;, 5~-..;,......~ g ~ Il:> ~ ~ r:::l /0.., r:::l'N .... .., /0.., I::l "".... ;::S't3 r:::l ""'", ..... 0 0.... ~ o<::>/o..,~"" G......~G~/O'" ~OOIl:>r:::l ~;::so r:::l......,'esi~ ~c....rr:::l ~, ~ ~C.) ~ 1S Il:> '~o :::: "I::l O'::;......~~~~~;::s ~ ~ ~ ;.,;) g.......~ s.~ r:::l ;.,;) ~ ~ ~ ~ 0 t;;, ~ i:::) .~ "'r:::l.oll:> <n~ ~ '"' ::::,.......~ . ~ eo ~ Q /0.., 'c-~ 00 ~ Il:> ;.,;)r:::lO OOOl':~ ~ ~Q <::> <:.I -..;, .~ Il:>"""" ~ Il:> .s ~ :::;: ~ .... ;::s /0..,... Il:>....... ':;:; ~~~ <::>~~o ~~/o..,'esi"'" ;.:: 0 ....-;;.,;)~r:::l ..c=:;.,;)...... () ~.... ~ ...,"""'.... I::l . ~ Il:> ....... Il:> ~ .... ..c ..... ~ ;::s ~ ~ /0.., Il:> t) G ~ ~ ~ ~ -< <Ii 0 ~ - ~ ~Cf)q ~.-{ ~ril~ S Z ~ j:;..j~~ E-ot <Ii~<i p..f:-;:;,. "'::<,....: ...... ~ ~ ~ ~ t:i.< ~ ,.;j v CJ ...... < r.A Il:> ~ I::l ~ ~ ~ .... r:::l ~ 'C) ''\ .. o 2. 1 7. 9 '6 1 1 2 a AM * MIL L :E R C R 0 S :B V MIL L :E R 1"02 t- .-.., ,..-.. IN THE CIRCUIT COURT OF THE TENTH JUDICIAL CI~COIT IN AND FOR POLK COUNTY, FLORIDA PROBATE DIVISION IN RB: Estate of AMr T. GUTHRIE, File No; 94 CP- Deceased. LB~ftlRS OF JU)JC%HISTRA.!I!ION TO ALL WHOM IT MAY CONCERN WHEREAS, AMY'!'. GtJ'1'HRIB, a resident of Polk County, Florida, died on June 6, 1994, owning assets in the Stat.e of Florida, and WHEREAS, WI~IAM B. ~ has been appointed personal representative of the estate of the decedent and has performed all acts prerequisite to issuance of Letters of Administration in the estate, NOW THEREFORE, I, the undersiqned circuit judge, declare KILLIAM B. .BAHNUM to be duly qualified under the laws of the State of Florida to act as pe%8onal representative of the estate of AMY T. GUTHRIE, deceased, with full power to administer the estate according to law; to ask, demand, sue for, recover and receive the property of the decedent to pay the debts of the decedent as far as the assets of the estate will permit and the law directs; and to make distribution of the estate according to law. WITNESS my hand and the eeal of this Court this f/.lz. day of June, 1994. rol[.. /.t/~.$"If;t) /d. f1~t7ljrf Randall G. McDonald Circuit JUdge CCR::UIr COURT BEAIJ ... t'1 J L r, LUUNIY HtALIH UtrAKIM~NI CERTIFICATE OF DEATH FLORID}. 02227 ,.,,-- ... nA1:J( f"LE1'lO. i , i IN ..K ). ! I 0.,-.-1 oS H-ltIo .....a 'R.-I..bihl~~ sPn,"- lJIVNON O~ Hf'""'lHI ....'1!II&tA' _ ~ ........... RI:GI&T"A"'S NO. I ~ "' OfC!,uto -NM4f l_H OA.T! Of DfArH i ..-.0....'11.'''..,. VIall, '1'" ".00.. IE ;/RY Flalu RO~~RT IOctobeI' 10,107lJ. HANtlUH I. lACf -"'". ,..to<<:>, ~u~..... ...ou..... AGf-L.ur D.a.H. Of l'uHH ,MONt". OA1. COUNTY 0,. Of....1H .n.:. I ut(,n I ':' 1.-, ~ .... ,..In~; l'l..... ..;oi~T-o....:I 1i_. I I h..... "e ----11, UC: lo \. ,i':ST[ 16 1R92 ,.T'olk ern, TOWN, O~ LOCATKlH ci-Dt"TH - IN~tf.). (In I....ra HOS"TAl 01 O?)4[a ....SrrrvnoN N4M.E t I' NOf ,... tt...... ColV; If...,. ANO HU~.. _ Ln'oulan,.l ...c....~~e.3 6 LHkg Hunter Driv'? ,.. ~ t\. -..... .I. U ,. J' ,. STAT! DlIl.not .'" ..v. ,.. u....... .....:[,OiiilN 01 ""H....T cciliHlU MAlt. "fO.. Nf. Vf~..' M.u. t.lO.=-rU. iV,...~. Sl'tMl-..' " "''''. G'V' _ow..'_ I I d io:-, c.,........., h <' f, WIOOWfO OI'(ORap 'YKIPT' 1\ T 1 .. n .'-4 t U.oJ ..-,.. " m8.rrl(~ ,j 11 ".my ay or 5'2""6 r57 ,,*JM&S-2; .~ ~~ciC~~~ :.-::;, ~- o. ~~.~ ..0" G' 1~1Ni> O'llUSM~ O. INOOSm---.- 12. -,,- '-1-- ,)4.... 11oHet. t'iir.ister m. Presbvterian Church RfSlOnOCf-STAI{ COOHfY em. fO_. ()It lOCATlOtl 'H''''' em ....... STltHf _0 NUM&U Florida Polk Lakeland 'IHWeYOO- 803 Lakeside 140. 1411. Ue. I". :J 140. t:ATHfH ~ ,..,r ...~ L.Ut MOTl'.E. MA.:olH N4Mi ""IOOU h'illiarn H. Hnnnur.1 Annabe 118 Eu11 igan i I l I I Court ......' II IN~-NAMt Nrs. A my Hannum II.. "..tf I. ,,""1L..c;. AOO"'SS IIn.n 01 a..... NO., (;In CM row". SolAr,. Ztf'J 03 Lakeside Ct. Lakeland, Fla. IT\. lENT.. OMY 0Nf CAUSE I'f' 1M ~ (oj. (1)). ItNO (<II 33801 Aff .lI.lilWlo J IIl"WU" OMMT ....... Oil CE..not w,u ~l) ty, 18. ~'" CAl.tM, , ./ {.l;:'~(t'/ /..i-i? (. (/'j \. / /; /Ih CO...."O..". II '''#If-I WN'CM GaY' III" ro .."ICHAn CAW" 1_. ,,,.,,u:~ Uti UM.,. LTING CAVW LA" l~! WI 1'0. 011 .. ... ~. 01: (<I "AAT H. OTI<U ~/GHlI'lC>>I' CONOIlIONS. ~0f?/V. wf I I IoCCl N, S1J _IClDcl, 011 UHOfTUMlfoltO ~ I...o-n., a.rt.T. YIA_' .- - " Y2S weal ."'.O'''CS (: I.IOIH_ .11I Of'.......MlQ t...- O' DI.'" 19\. CQ..caI"OMI cc.>><<...v..... '0 OlAtM ." ..0' Ilft.Ar,o '0- (.f.VN Orvl" I" MAr. .., / /i{t.-, ~'~6~ HOW ."UU.' OCCU..EO c .wn. ......n.... 011I INjUn IN ,...., t Ott '~,'r ". fT.. 'a. ~ /', /. --r~'./ / fY' I/of." t SUt" 01 '.III.b. NO., Cln 01 ,OW.... irAn) 70<. lOCAnON INJUrY AT WORt: C .NC1" "' oe NOJ 7lIt P\AC! ~ tNJlJIY A' NQ.loIlt. III....M. ,,.,,. '1/IrCfIOIIrf. C,WKI ""'_. 1ft. C II'IC'". 200. 2tlt 2!lI aR'l"lCAT~ -'" DAf .... PHySICI....: 'TO .!r~~~~';;;~.~~ /91: (, I 't~ 15 I i.~ CfRTlfICATION-"'EOtCAL UAMINE. 0. COIlONU, ()o.I ,.., ..... "" ".. f...............nOH 011I TM! 11001' AHOfO. fMt ...,y.ntG.'tON IN"Y Olll....O" 0....'''' OCC\l1HttO ON Nt Dan AHO DUll' TO T"f CAUU.S', SU''to . no CEllnflEll..,-NAMf ,"'.. 01 n. (j) ""--' (.')/'. . MAILING ....00tlf~. (f 10 71d {/ ! (~".,r .-.::/ aVIllA!.. CREMATION. RtMO......L tU,!'ft"' 2..tlS m ova 1-0 ur ial o....B t 144 c . fUN~ ll\ I~ .....0 loll' $.A" "*,/WC'e AUYI OH MOo-ffW DO ttld _1M ...., fl.. 1'/ ,b.lt Fla. 33~03 ( . , ':.) I hereby certify the above to be a true and correct copy of the Local Registrarls record' on file in the office of the DIVISION OF VITAL STATISTICS, at the POLK COUNTY HEALTH DEPARTMENT, WINTER HAVEN, FLORIDA. MAY 0 2 \979 DATE ISSUED WARNING: , j:' I' i..(../~...L--'..... ~_. lJ..l.,.,u..., (,/"-_______.-{ _' County Health Officer ~d Local S E A L Registrar II /7 /; ( -t 1'1. ''7:,) i-1, {:7 -rn {'iL CHIEF DEPUTY REG!STRAR NOT VALID UNLESS RAISED SEAL OF THE DIVISION OF VITAL STATISTICS, POLK COUNTY HEALTH DEPARTMENT IS AFFIXED. OJ s; ~ ~.~~- tl gJ~.. - - '< c::F6 g t:l""::1, : ~ .t1=- o '-q' , ... - r;l.,fr.' Ootn l:l .... 2:_tn , ::::. a (\) - 00 ~ S' ~ ~ ~[:g g or;l. ~ ~g X'" g ~ . (Ij ~ -:x: ;':0 -0'" ~~ ~ 3 < ",..., .... ....w :5l> -". -:0 ..., <Xl = _........: '" -:\~ * '\ ..... ~,"""'" C" I , .:" ,.'~. ". o?:l fI' ~.. '-:;:'16.:'-';""'''' -. ~/ ::~:: . ~. 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UNDER 1 YEAR ...... 5c,.UNDER'1 D.v .... .......M ....)i,iin.x~ ",;1QQA ............ .............. ....... .....'jI';.,~AI';-Hli( ......... ........... ......... .........tyf/7/" ........... 1\~on'~.O.'?i s~rsl'-1'1W. .i/t;I~g~1'EOW BIRTH (MOnlh,O.w ~.')>.IJBI~1~PLACE (CIty .nd State 0( FoteiQn ~nrry) ~<> ..>i e. :~~g~~~~~M(':f ::;~f. '. .' DECEMBER14.j<!898 DELAWARE COUNTY}OHIO<Y>.; 6~~~~o...<.. ..... j ~ 9a. PLACE OF DEATH (Check on/yone: a.. Inatrucriona on other aIde) ..... ........... ....... 9b. INSIDE CITY LIMITS? ('!loa Of I'~ {>: ....t? .!iOSP1TA~:~)f\Ilallenl -,ER/OuIPallenl~OOA,OTHER NutW'~Home ReSIdence _OIher(SPf!l:ify) ................ ........ .......yES <. ~ , ~> ~c. FAClY10' N~~E (lfnIT'insI0'.pMtar~r.~d~~m'\rl ............. iY 19d CITY; TO\'IN. ORl.OCA.TIONqFOEATH\.)~~: COUNtyOFO~TH . i:< > ... T Nfl < ...<:>p>> POLKi> " !!l". lQa. Dr'~~T'S+UJS~UAL.]'~OCC;~JyUPATION lOb KIND OF BUSINESsnNOUSTRY ...... 11 MARITJ.... STATUS -Ma"F~7 \122S;UURRVIVING SPOUSE ('I wile. rll1Ieme/den nitme) , ~~i.'. ......... '.' . ..>. . .......1 .'. Never Marnell. WJllowed. ii > Yi. i 00. ......_D~i..i>ii_ .....1. DIVO'Cecl (SPf!l:II)o)\:> , at' TEACHE$.'>>' .. . EDUCA'l' J: ON < .' .'< I Widowed./> .. .i.. . '. ...... .<> .~ }'. ..... ='3a'?i~I~~0.~ir-r;:71:..:UNTY '..... 13c.CITY.TOWN.ORLOCATION.. .....'~STREETANO.~.~:BER. . . . ...Pi'" i'.r.. . . '. ......,> .....il ''IT.K'/;?' <;.j> \\.iY .Y>: .........>...:IJ! 6iL~ ~;&~~kRbiIV:E' ~ . / ;J!il~'!:i~I'Ol!l CITY ')3f~IP COj;DE 14, WASOECEDENT OF HISPANIC OFlH~A.ll'It,AN; ORIGI~" 15', RACE;:. Am.ncan, 'oo"~,'~a.n.,, 16. DECEDENT'S EOUCATION..... '.: " . . 4t"1T:~?~}lrllol.... (S~Noor\9a-lfyes;apecIIyHamart,Cuball, ....... ...<...iBlaCk;WMe .,C /IS~f,Iy?~Yfl'9~e.,graQ'a~~, -.. ,..,..... ........ , .ii !1ex:t:tJll, pij~~~R)lca". .,C) -- ~ - ;;;)' S""9'Iy. ~'" ..1. ..; ..'? />}~~g>/., /~(i .............. ...............(i/...i./ ITF.~r\'410~~fIJ~S_ l.~"........;.;: :' ~'.17. FATHeJl'S NAME (FirSt Mtdd/a Lasl) .......ii................./..:.< "'1& MOTHER.l1!\1~~EfFlntMtdd/a. Ma/dsn SU'~~~f/. .lj .... ORVILLE TAYLOR EVA STRONG ..i) "?iiA 19a INFORMANT'S NA~~q~~~, i_i< ....I/~;MAlI.ING ADDRESS (S'feer and~~0~~or Rural Route~~ Ci'!(%'~f:sratl!,ljpC~J ..' ~(.\I WILLIAMO.Hi..HANNUM:./ir..>213 ARLINGTON.AvE~ ..<NAPERv:friLE)? iLLINOIS, 60 !,j'~ METtf9D OF DISPOSITION)./ 'i '.... 20br!;ACE OF DISPOSITION (Nams oI'cem~. ~Tawy.~"g: . ?Pv' l.OCATlON~ Qift Of~n. r1~Ie-'... .... ._ B~6lii _ Crra1iOi\7:..A'mOYall{~ ~e ')/herp,ac.). . .... . ..........,.,n<< '.. .' ./iH , - ~.. - OItl<<" (s~2~7~~7~W..iLAKEVIEW CREMATORY))>> WINTER.H~~E~i4 tLO ':' a SIGNATU~...sFJVNERAL SERV~CE CENSEE OR....ii 21bi!iICENSE NUMBER 21c'~!\~~1i'D ADDRESS .oF FACllfrY .ALliZ........1 lEi ~RSOyACT~NG suc ~~ ~' . (Of LK:.naB8) Thornlon-Holcom Memorial Home....... . ::....:.'/){............ ' f . '.' ....... 183,}.SQ!f111 F1~rida Av~.I}.'1.~. . ....................i........,:....'...,.. . .... : i '~'U'b y..',i ..... ./.2033.. }}. 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JL\ ~ Lgp: REG'~TRA~ ~- ~~~NATV~:'-_" .ii... ... . ..' .... i '. . H' ~ D~~R~~ISTER ;:I.JIlc.:;,L'''''' ....'Sio~ 6+.Jj4~" .... ..... '.- Z.1.1.}( ;o""tih..af#~;''r; ". ~Va . .'''' """"'~:f,:,::::;;=~:..~:- ..':::'.....~!::i:-'"~'" .... .;>:'~;;t"'-~~~y;.....Hf~f : .... ~~~:..~\~~~~~,~~!r:~...:i. . /'."dri -,--..i// ..... ..... . .~..". '.. >>.,. .. t:,~:' r ,~.~~. Wi \ "~,:i!':!}, ,,~~;.:,,!;(=;~~:; 0\"'t:":~}~ ;t}:'~! , u:~~ Ii :: ,V"rc .....(;~&.-.)?;.;)~!,~.v7:,i.;~j' ' X ~J:e~~:'~8.D~~~~ . ".i. . /~~TOIB~~~CON~~?~~~f~P~)} .i}. . 73T~~i .,T:j<:t? ....... .tlla! Initi~edllVents .."r/.}c,' .ii' ... :,. .bi..i(... .. iii,X"i/'.';' ....'..... .,.; : rr~~*;:~:;f;.~lhl~t).. DUE TO (OR AS A CONSEOUENCE OFj: .......i:. .... I........, ..... :i...}....,..:../> d. .<. . X.. . ...> ...... .i'.'>_ ...1 '........ '..... ...PART II; Othe's'l1ntfiCai\tCOI)Q~lonscon'~ll><Iting 10 aealhl><l' no\rea'_U[Il,~"ng Inl..hVeX . ....... 27a WAS AN AUTOPSY.~7~?WERE.AlJTOPaYFINl;lING~1..": h.~~. CASE REPO " ....:~e'lrw~ cajj(gll'i\Pai~dii ........... .....i . . . . 'i" PER~~:o~\j?F.. USED TO ~J~LETe CAU~~ ...... .... Ii TO MEDICA} . 'A . i "Xi> }(Xi '.. .r" Y/ ::i H.i( ........ (Yea ~t~d.j' . .'. .' OS~~ATH~.~(Smr N~l <is .......... ..~:~~~f ')i ..>. .29. IF FE~.:E,~~TH~~E!8E A .... '30:IFS~~~.~~V IS ~:N;IONED'~PA:l?,IlE~IE~ CONDITlON~~WHIC~JrWAS~EAFQ~~W}il ':~. ~JE OF~J~~e~;~~.:~~ay.Y~ .....\.;.'.......... = ... ... PREGNANCY. IN THE: PAST .i/:;.. <'.' ....i\ ..... ..i...........ii . . ..... ..'X'. I.'..... .........."'..'...:?;.. .. ... j"H I...... 3 MONTHSr\:iy~s.. N~ . . .}.. .' ... . .. . ..................... . . .' ....... I..: '. . .,i'i .'. ......1 31, PROBABLE MANNER OF 32a DATE OF INJURY 32b. TIME OF 32c. INJURY AT WORK? . _ ..1.2d DESCRIBE.HOW INJURY OCCURRED . ............. ....:1 , . ~" .PEATH (SpecIfy):..' - ....JMot.IIt.Oey;-'l'a",.'-. IrjJUR.,...\.Y~S()'NO)i...... ~...':.'-......-'-- -. ..". "J. ,.\; .' .;i~!F~~':~~; . .......... .:I..? ...: ir M'..( .::> .ii }X\ .......... .j? "'H '.' .................{(. . . 32~.PLACE.?FINJURY Alho".,~:Jar\. .....j2fLO~jTI?N(SIr8~ralidNumber;~RuralfolileNUmber.~0orrown, Siate) .{< "J "Ci))!t;C, ;;, T]ii~" ~ ~}",i T.S!,; .... ..\:S; v};:.~!~r! r i:':'i, f ...... ..............,...:... ..' ........ ...... ...........;... ........ '<..ii.' , . ....,............................ ...... .,. ..... ...... ...... t, \ . i.....>? <,.. .. _ ..... ...... ....... ........./ ..L<'< ." ...:. !:}. ...... . ........ II ~ TS .P: ~~TIFIED TRUE AND CORRECT COpy OF THE OFFICIAL REctmD 'ON ri~:jN;'T~icE' '-,- . ]'77""'7 ,- 'S? .........:.. ........ :L /J OQ.te. :CS5uect .Q~N ~. 1994.. < ~ ....iC 'i-.BY~. ...~ ~ State Re '!strar..i i < .... i..<i..... j; ~'tH8"~!!l.............i .......... ....": g........:......... ........i<..-.i .i<. ~j.r..~.<.......... .............i.../................. 1if/;, "1' W ABNING. ANY REPRODUCTION OF THIS DOCUMENT IS PROHIBITED BY LAW. DO NOT ACCEPT i"" . '. lilll.. ":l~l~ · UNLESS ON SECURITY PAPER WITH LINES AND SECURITY WATERMARK ON BACK . . r.. ii AND COLORED BACKGROUND AND GOLD EMBOSSED GREAT SEAL OF THE STATE OF. ~ :,'t . ~"J" i' 4SS- 0 5~. FLORIDA ON FRONT, ALTERATION OR ERASURE VOIDS THIS CERTIFICATION. ......~ :'\... '+~....'" 4- 0 4 ." .. ._ _ HAS fORM 1564A (6"93) ~O-..TN ." ~. ~. " , ~.' s ,~ " . . . . . . .. "'A 4x11.: ~ ~ ",'~ " . ~ 'r " t ~ IN THE CIRCUIT COURT OF THE TENTH JUDICIAL CIRCUIT IN AND FOR POLK COUNTY, FLORIDA PROBATE DIVISION IN RE: Estate of AMY T. GUTHRIE, File No: 94 CP- Deceased. LETTERS OF ADMINISTRATION TO ALL WHOM IT MAY CONCERN WHEREAS, AMY T. died on June 6 , and GUTHRIE, a resident of Polk County, 1994, owning assets in the State of Florida, Florida, WHEREAS, WILLIAM B. BAHNUM has been appointed personal representative of the estate of the decedent and has performed all acts prerequisite to issuance of Letters of Administration in the estate, NOW THEREFORE, I, the undersigned circuit judge, declare WILLIAM B. BAHNUM to be duly qualified under the laws of the State of Florida to act as personal representative of the estate of AMY T. GUTHRIE, deceased , with full power to administer the estate according to law; to ask, demand, sue for, recover and receive the property of the decedent to pay the debts of the decedent as far as the assets of the estate will permit and the law directs; and to make distribution of the estate according to law. WITNESS my hand and the seal of this Court this ,f ut. day of June, 1994. .. lill1,' L..fL~S4AJ iL-J 12~{:7jn Randall G. McDonald Circuit Judge <CR;W COURT SEAL) RECEIVED f E B 2 1 1995 CITY CLERK DEPt.