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Brown, Virginia Campbell DRUID CHAPEL 800 EAST DRUID ROAD 18131446.3055 ... ' - IfuoDES FUNERAL DIRECTORS, INC. ~. .. '" BELCHER CHAPEL 830 NORTH BELCHER ROAD IB131446.2222 P,O, BOX 895 CLEARWATER, FLORIDA 34617 AFFIDAVIT I, Tom Brown, Jr., certify that my wife, Virgina Campbell1 Brown, was the only surviving descendant of Fred Campbell and Alida"MaillUonl\Campbell. My wife's only sibling, Donald A. Campbell, died a number of years ago. There are no other relatives who could have a claim to the burial space at Clearwater Cemetery, Lot 17, Block 6, Spaces 19 and 20. Fwther, my wife is to be buried in Space 19, next to her mother, leaving space 20 for my use at some point in the future. r/~~ Tom Brown, Jr. 1002 S. Prospect Avenue Clearwater, Florida 34616 h Feb. 9, 1993 Wi~ ill Feb. 9, 1993 Pwmit No._:....__;..._..:.lji;;;;,~al Permit No.~_~__ , i,4," 'Lj/1i,~ Embalmed by__,-_,-_,-,-_~~":'__ NAME_4~_~~____~~-,--- , ,", ' '. .,,' ',' ' , ,,',' ;b--- ' . JOlIN S. RHODES, INC.~eferred by______________~----~----------------- " " " , nt' E "T " '. Trarn________________ FUNERAL R C ORS Directed bv----------------. Cemetery_____________. ST. PETERSBtfltG . OLEARWATER FLORtDA Time in Hospital 195 .,Date City Residence Out of Town Residence Time in City Street and Number Social Security No. ~ ' Color~ Widowed~' Divorced War Service 'sex~ Single Married Relationship of Age of spouse Date of Birth Age Not For Paper Age / 0 Days Birthplace Citizenship Occupation Name of Father Birthplace of Father Maiden Name of Mother Informant Cause of Deafh 'Doctor Attending Funeral Service "Ch~l ,. Place ,Inr. Qitipel . Church !finister _~, ~ Casket Rosary .------- _.- Couch Friend, Rec'd 195 'J.aid Out Family Car ----rn /t-;--- '-,. " '. ,- ~'~'liP:';~~r~ !if 'i;.~.lff!~P.J~~l Date ___ __ _ _ __ __________ _ _..: ___ _ _ __ _ _ __ __ _ _ __ _ __, Burial Removal Rec. Vault Cremation Place Checked to Lot I 7 Via Block (, Grave Div. Sect, ~'~r.t~ I c:~id~- day, f/ 9 195 " ~~M. Date Remarks C, ",~I.' _-. /, c"..., ~G ,'>~_t:--7 C:rJ.. 'ruf~ , ti ';2?~ ~ ~ f~ t2-/{' ~ ' :J:>tJ~J :'::':"":~'i!,'ti':' ";.r"'j",; ,I: "'l).};" ,,"... ",",;(/: REeOB-p,OF FUNERAJ!!l!iV,;;:; "I' Pi ',..",:."",...1""'",.".,.,,'.',',,.,,:,..,:., ~O',','"ita',".".'"','l,',,,!," N, 0:,.,.,.'::'.: . . ., . . . . . Yearl;. NO...: ~ ~~.. . . . ." Date of Ent<}'. . . . . . ..~. :. .?f ~: . . . .. .l9.:fb ":,\' :.,N""';OID.;....oo...... .C]4)P,-<... Jt.Yt,;'..{J.~........... ......::.... .:n~... "..;. '. ' " ':, ..'"..,,",';!{j'lr.'i:.~;~M,a~ie(- 9i~ngle. ,," .' '. ~Wido~od, 0 ~iv~ced: DHuobandlZlwlleDwidowf j'~ · ~,' (VlhA Race) . ai~:.<,' ,.~',' ' , .:,:.;,',., R,e",s, l""d",.e,nc"e.,;l".".,.,T;"",.", ..f,.~.." ,~.,.... ..V;,.., ... ~".",...,.. ,......., ;,' .'.... .......,. ,,,,,,.,Jf~~./.,...r 'i I " W J f Ag f H b . W f (fl v g) 7~ Y".":",, .0'..."."""",:'("'1",..".",',,,.,.,.',.:,'.'',..":.',.,':'.',:.:'"',,,',.,.,..,.,:;':..",.,.,','.':,'.:,..:"",',".'.",.",['.".":"",',,,.',,..,:,'.',','.""...""".,',',.,.'".'"',,,.,..:;,,:. "~"""'.'"',,"',',, ',',',','.,',""',,.,',.,",'.,,'.', "',,',,',',',',' "',' ",.'""',',.,.'"'"'",,',,".',..'...,.:,,rd...,,,,.,'.', ,," "'.,'..',,,.,,',',,', (f)~", ',',' " ' ,,",' , ',',',' " ",. """.",.,.,.,'.",'.'"". , ,or...... ...........0 " 00 "s an,"', ",0, ,r""""""'..,...,.,,,,1 In ,........ "..,..... ear' ,,' " , ,\ .,..::Chafge..to ;'t~'::?:". .. ..:,:: . ';.,' . .. ...... ..'~ .'.. ,"'" ,,' ' ", . "; . .';' I,., /,.} S- .i:~ ' ,'" Co~plete Fuo...al (except outlays) .. . , ,. ., . , .. t . #~. ,,,, " . .,."".1 Ad?r~~" .. : ' ! . .. . W .. j . J, ....;:p : .~: ~:: Casket : ~ .. .,,' , . : . :';.i -1," b,.t',""';,:,I'),:'1~.;:,~~...,~~,i,, i. 6rderg;v~$;.. .. .,1-:.. .. ..', ..... .l"~'< Burial V.~t .~; iio~ : : : : ~ : ;L\\ ::: I r.~. .. . ... ' ,'. ,'"i', :,:...'," ';,:t,,',:/ "t', (orlnfonnant)', , , " , ' ' '(Stat. Kind) , ", '," ;; ",' ',., I, i' ,:,' :', ,'. c:....:..-..--1 ,,', , " I' 13 d . ' .': ',"., . ,<:.", ".,\iHowSecurj;lrl.~:; ,.,.....,.. "VJ,_.~...,................ Emba mmg 0 Y ...... ...... . ;. ..',;',',.,:.:',",',',.',.,:.',"~',!":"",i,,,,~.,,.1,,'., / 'IfVeteranfi~t~te Wj' .. . .. k. ~,. " .., :.. ..., . Bal'b..., $.. .. ." . .. .. I1~7 D~g:' $. :!,,' Y!<. OU:i : ': '.';5i:~: ~'" "/ .-J "Dressing Body, $.. .. .. .. .. Underwear, $ . . OccupatlOn.:'...... .......... .~~........... Suitor Dress ' '. .' ,'. ,..i.,,:, " ' 'v;, _, ,> <fi!,ciaJ S.curity Number) . . . . . . . . 'ujt~t~ 'Ki~d' ai.d C~J~;)' ' . . . . . . , EIl1plC1y~r~~dAddress .., .:~ ,.{I:"tt-;.~f'~~'~'" Slippers, $............ . Hose, $.'.. ;;'... ,..... Pllte ofD~a*. .. .. .~. J t.. ; ~:. ....... '1.:J~. !:.r '!YJ. Folding Chairs, $. . .. . . . Tarpaulin, $, .. ,'" ., ...... '. .;:, ",' ~(Dat.)ytO _' j 8 i I (Ho) Candelabrum, $....... . Candles, $... ........ ....... Dat~ of Brb.. .. ;. iJ :..:..:. '.' . .. .. ... . .. .. .. . .. .. . .. ." Doo, 8p,"y. $ . .. .. .. ..Gloves. $. . .. ." .. ..' ......' Age: ...:.... ~~'....... .., . .61..;"';",. ...f .~..... .....' ~neral. Car, $C....... .Ambula@nC$e,$........."..... '.." '"..:,::(~:)..N (M~tb.), (Days) Llmousmesto emetery..... .........., ,...... Dllte ofFuneral~. . . (~~ . . ~. . . . . . ... . · JJ. '~" . M. Extra Limousines. . . . . . ., . . .@ $ .. . . , . . . . .' ,...,.' , ' . '".,:: ' (Dat t1J' hD::J..~;.kb- (Holll) Autos to R. R. Station. . . . . . . @ $. . · . . . . , . . . ~ervicef3 at,.,.,.",~," .... ....~....~... , .,.. .'.......: ....,.. Get~ing Rem~ins from...... .... '," .,.,' ...... ,ii Clergytna'[l ;:)~. . . . ot:!. q. . . . . . . . . . . . . . . . ... Takmg Remams to. . . . . . . . . . . . . . . . . . . . . . . .. ,....\. . ,'," ',.", ,d ... " Trip to Coroner's Inquest. . . . . .. ., . . . . . . . . ., ......' ,,.It,e,lig, i?n, ?,f'""..,.,.t"h"".."",e,Deceased....,..;. . ..... ,.,~. " .... .,',..,.".,.'. Del~vering Box to. . . .,. ',' .............., .. .. B'rth l,c"e,"",," ,?if [L .', -, L.---..J_ ,~,', DehverFlowersto....................,...,.., 1 pa ;..,..~.;'~J:'I................ ",,',': ,,'2y'~~", ,,: RemovalCharges........,................... R~sided inthe ~tate.. .. . . . . .. ..;;. . . . . . . T....,. ., ., ......, Procuring Burial Permit. .. . . . .: . . · . . .,. . . . . , ~i~ce of be~th... . .4-. r?: ~rre;.::;.;J...~. ~~:n.~.~: _Certif.CopiesofDeath ~~tifi7:t~;NoDolstrlct) .- '" ' ,'" ' (State Physician'. or Coron.r'a; Ca~se ofD~~th. , . . .. . . . . . " . . . . . ; . . . . . : . . . . . . . . . . . . . .. Pall Bearer Service, $. . . . Use of Chapel, $. . , . ' .' ", i ': Gross Total for Sales Tax.. .. .. , . .. . . .. .. .. . $ .. .... , ContributorY Causes. . . . . . ,', .. . .. ", . . .. . . . . . . . . . . . . . . · . ',' Outlay for Lot , . . . . . . . . ~ . . . . . . . . . . . . . . . . . . .. ....... Cremation. . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . ., ,...... 6'e, ~;fY' ~~rp,,' ~y' ~;~i~~: ::i!:h:: . . . Qk : : g;Sl: Flowers, $. . . . . Palms, $ . ; ~ . . Matting, $ . . , .. ,...... ....., , ' .,~ ,I " or Coron.r) ~ ~n Rental of Tent, $. . . .of Temporary Vault, $ . . ., ....... H. Add -J",X"'" Opening of Grave or Tomb. . . . . . . . . . . . . . . , " ....... , l~ ress. . . . . . . . . . . . . . . . . . . . ., .I........ L" G $ L' . D . $ I' N.... of~atb"',,~' . :11.,. .?Yl~. O~;: i::~~ip~;~~ Ch~;:n.g ..~I~~: . .: '. :', ::::::: H. '0' th I J1. 7.A Clergyman, $. . . . . Singers,$. . . ,Organist, $. . . . , IS,JJI,r pace.........:~... ..:..-1................'... Railroad}T' k $ Aero-S" . $ /J) or Motor Ie ets, ........ plane erv1ce"...., Maiden Name of Mother. .'i?:......~...~.,.~,...~.... T I Ph C bl R d Ch , "........--~ e egr., one, a e or a io arges. , , . . . . . Her 'Birthplace. ............ ....... .'?-;~!.~........., Cash Advanced. . . ., ..................... . , ,Motor} " . lOut of town Undertaker's Charges. . . . . . . . . . . , Ship :ft.emam,jo. . . . . . . . . . . .~. .. .. . .. ";4t' . .. .. .. ... p.... al Serv'ce . ~r'" ~ II: .."P _ ~ "rson 1. . . . . . . . . . . . , . . . . . . . . . . . . . . '. S~ze of Casket. . . . , . . . . . . . . ., y. ,... . . . . .. ...................................................... , 't db ( t cO~~~~1 ., .'.line Death Notices in..... . Papers ......, Manufac ure y. . . . . . . . . . . ., .................,. . . . . . . . . . . . . . . '<i,~';'';''~ N;";'~~~~) . . . . . . . . . . . . . . ........,...................... .'........ .'... Lot No.. . .;.'. . .. . .. Grave No..., .... ..... " Section No........... BlockNo..., . . . . . . . ~',', r' . .............................. .'.... .'....... ,',' ,. Sales Tax ,. ... . . . . . . . .. . . ~. . . . Total, Footing of Bill.. .. .... .. Less.. . . . . . . . . . . . . . ... .'~ . .'. . . , " Owner.' , ..' ~..... .,_.. {'... ~alan~e. . ~ . .,. , . . . . . . $ Entered into Ledger, page..... .or below. I Date Amount Paid Balance To Above By Payme " " " " " ........... ,....... ...... ,.....~. ...... .....:"...... . .. .. .. .... $....... ...... "...... ...... ....,..... 'o''' ..,........ $..,.... ...... $....... ...... ....;......... " " " " " .i'" , Names of , Insurance " . .. .. Jnsl!:ran~~....................... .Lodges.,....:............ ~... .................... .Companies,.~,;.... 'IL .~. ..;......... .... .;:. ....:.'.:. ~ J1erebY ,!-uthorize the above Funeral. and I hereby represent that I )lave euftlelent resources Legally avaUablll ~. . . . . '. . .:; : . . . . , . , . . . . . . ... ;. . ;' . . ; .'. . . . j:';' . ,: .." " '. " ,,' ",'.,:.".,',,". (FIrm~OD1eofFuneraIDlrecto...);:' .," tOl'th~ r:~F~nt of aforesai4 ~um, aue! I llerebr eOve~ant an4 "'~ to pay the same within. .......!.,. ~".' "', .dar'f~~m date. Interest t~~eerue from ~~tM~aphe rate of. . . . . : . . . .. . . % ~r F~'..~i:::: . . 'I:: '