McKenzie, Alice LyonA, RcCtt?D 09094499
CEMETERY DEED
OCT 6 IO 32 AM 269
THIS INDENTURE, Made this ____-? S th ----- day of
G.P. 3177 PAGE 57
September------------ A. D., 19_69__
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 ______ d__ic_e __ Lv__?---on --Mc---Ken------zi--e - ,-------------------------
------------------------------------------------- of the
1375 Jeffords-St., Clearwater
------e f o--to County of __incll __________, State of _ Florida ---------- party--- of the second part;
W I T N E S S E T H : That the said party of the first part, for and in consideration of the sum of
$ Foux _ hundreddot 1_ars__($ 4 0 0 , 00 )-------------- to it in hand paid by the said part-Y-- of the
second part, the i ceipt whereof is hereby acknowledged, has, remised, released, and quit-claimed, unto the
said part--y- of the second part, and--_he-C------- heirs forever, all the right, title and interest, which the
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' said party of the first part has in and to the following described parcel of land, lying and being in Pinellas
--__- Block--L4 -------- Clearwater Cemetery,
c5 County, State of Florida to wit: Space Lot __?21 _
29-30
O
?. • "I as recorded in Plat Book__ 0 0___ Page_S______ Public Records of Pinellas County, Florida.
- _o
> wi 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
v
-7 c3 only for cemetery purposes as human burial sites.
,- TO HAVE AND TO HOLD the same to the only proper use, benefit, and behoof of the said
part--y---- of the second part ------- he-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 OF LEA AT R, FLORIDA
in the presence of us:
_ ------- ---- --------------
-.' By City- Manager.
---'l Chi - - k ------------ Coun
__c-Z~
------------------------
ayor Commissioner.
Approved as to form and correctness: Attest: "
------- - ---- --------------
rney o City Clerk.
City Attorney STA-FEE ? t= 4'? `?-' I ;__''
C(UPAPTRvLLER fy?3wx ` - -
State of Florida, t? - G. - OGT - 6'6 9
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County of Pinellas: ° 10 s 21 Personally appeared before me,
and ___ R?__( ,_slhi-tah-e_ai_________________________________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 cor-
poration, for the uses and purposes therein expressed.
Witness my hand and official seal at Clearwater, Florida, this the------ ----------day of
-- ----A. D. 19_ 41?7_ ------?G? -----------
(Seal) Notary Public State of Florida.
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My Commission Expires Oe. 22, 1970
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OFFICE OF
CITY CLERK
C I T Y O F
October 3, 1969
-i rs. Alice L. '1c Kenzie
1375 Jeffords St.
Clearwater, Fla. 33516
Dear Mrs. McKenzie:
C'1,] AhN1'A.TE,H
POST OFFICE BOX 4748
C L E A R W A T E R, F L O R I D A 3 3 5 1 8
IXTe are enclosing the deed for four -Daces in Clearr,7ater
Cemetery.
While it is not legally required, it is advisable to
record this deed in the records of Pinellas County
throuf,h the office of the County Clerk at the Court
House in case the original is lost or destroyed.
Very truly y s,
.' X11 t:a hcad
r.?t I,Clerk
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AFFIDAVIT
STATE OF FLORIDA)
COUNTY OF PINELLAS)
I, Patricia Alice McKenzie, the undersigned, do hereby attest that I'm the
descendant of Alice Lyon McKenzie, my mother, who is buried in Block 14, Lot 571,
Space 4. My father, Bernard Leo McKenzie, is buried in space 3. My mother is the
owner of Spaces 1 through 4 in the Clearwater Municipal Cemetery.
Please take this affidavit as your authority to assign interment rights in Block 14,
Lot 571, space 1 and 2 to myself and my sister, Margaret McKenzie Hanson.
I 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 as
stated above.
SIGNATURE
(Name)
°
ADDRESS/PHONE
3 s,5-
SWORN TO and subscribed before me this
by t Qrr? c.?a. k >qc KA.,l1A-
identification in the form of 'r-i- oL-/r v-e-s
take an oath.
day of V
who pr
and who di /did not
go!/
Public
PATRICIA SULLIVAN
M commission a
Y •__
I Commission # DD 993869
a Expires July 10, 2014
p F ,°,P Bonded Thru Troy Fain Insurance 800-385-1019
FLORIDA DEPARTMENT OF
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
A.
1. Name of
Deceased
(TYPE)
First
Middle
Last
Date
of
Death
(If neither, give street address)
Month
Day
Year
Mice
McKenzie
June 14, 2004
2, Place of Death
County
Pine lIas
3, Name of Medical
Certifier Pamela
City, Town or Location
Name of
Hosp, or
Inst.
1375 Jeffords St.
Clearwater
Grover MD
Address
807 N. Myrtle Ave.
Clearwater, FL 33755
Phone Number
(727)
467-2400
Medical Examiner X Physician
4. Name of Funeral Home/Direct Disposal Address
Establishment Rhodes Funeral 800 E. Druid Rd.
Directors Inc Clearwater, FL 33756
5. Check a. D The medical certification has been completed and signed,
Appropriate application.
Box
Fla, Lic, No.lReg, No. Phone No, (Area Code)
(727)
446-3055
2632
A completed certificate of death accompanies this
b, ~ Pauline was contacted on June 14, 2004
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. Grover will complete and sign the medical
certification of cause of death within 72 hours,
c. D
was contacted on
, He/she verified that
, Medical Examiner, will complete and sign the
6, Funeral Director/
Direct Disposer
ause of death within 72 hours,
F.E. No.lReg, No,
4332
Date Signed
6/14/04
B.
BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body, Permit No, 2170-555
UJA five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has
been contacted by the funeral director and will not be able to complete the medical certification of cause-of-death section of the death certificate within
72 hours,
D No extension of time for filing the death certificate has been requested,
Registrar or
Subregistrar Signature
Date
Issued:
Date Certificate
6/14/04
6/25/04
Due:
C,
AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA
Approval Number:
Date
Medical Examiner, . gave authorization by telephone to
Funeral Director/Direct Disposer, Date
The Medical Examiner's approval must be obtained before disposal by any of the above methods, A waiting period of 48 hours after death is
required for all cremations,
D.
Method of Disposition:
CEMETERY OR CREMATORY
Place of Disposition City of Clearwater Cemetery
:U!BURIAL
o CREMATION
Signature of Sexton
or Person-in-Charge
o STORAGE
Date of Disposition
o OTHER (Specify)
}
This permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton) and returned
within 10 days to the local County Health Department in the county where disposition occurred,
DH 326, 8/97 (Obsoletes all previous editions)
(Stock Number: 5740-000-0326-2)
Distribution: White: Cemetery or Crematory
Yellow: Funeral Director or Direct Disposer
Pink: Local Registrar
INSTRUCTIONS ON HOW TO COMPLETE THE APPLICATION
FOR BURIAL-TRANSIT PERMIT FORM
APPLICATION FOR PERMIT
Section A,
1, Type name of deceased and date of death,
2, Indicate place of death: County; City, Town, or Location; Hospital or institution (if not in hospital or institution, give street address),
3, Indicate the name, address. and telephone number of the Medical Examiner or physician who is to provide the medical certification of cause of
death,
4, Indicate name, address, telephone number, and license number of funeral home or direct disposal establishment.
5,
a,
Check if acompleted death certificate, including the completed and signed medical certification of cause of death, accompanies the pink
copy of the application for Burial-Transit Permit to the Local Registrar of the county in which the death occurred, (If the completed
certificate cannot be obtained in sufficient time to be filed with the pink copy of the Application, check 5b.)
b, Provide the name of the person contacted in an effort to obtain the name of the physician who is to complete and sign the medical
certification portion of the certificate, and the date he/she was contacted, The person contacted must be either the physician or a
responsible person who can speak for him/her.
c, Check to indicate if this is a Medical Examiner case, Give the name of the person contacted who verified that the Medical Examiner will
--.--completeancf signlhe -me'aiCa] certification 6f causeol aeatnand Ihe'datecontaCt was made, --. - . -'
6, Requires the signature of applicant Funeral Director, FE License number, or Direct Disposer, Registration Number, and the date the Application
was signed,
BURIAL-TRANSIT PERMIT
Section B,
If it is anticipated that the certificate cannot be filed within five days from the date of death, five additional days (exclusive of weekends) may be
requested and granted by checking the box provided, If no extension of time is requested, check appropriate box,
The Registrar or Subregistrar who issues the Burial-Transit Permit will sign and date the Permit Application and assign the permit number. Section
382,006, Florida Statutes, requires that a Burial-Transit Permit be obtained prior to disposition or removal from the State and within five (5) days after
death, It shall be mailed or delivered to the Local Registrar of the county in which death occurred within 24 hours after issuance, NOTE: It is not
necessary to wait until the Funeral Director/Direct Disposer has custody of the actual body to begin the paperwork,
AUTHORIZATION FOR CREMATION, DISSECTION, or BURIAL-AT-SEA
Section C,
Approval for cremation, dissection, or burial-at-sea must be authorized by the Medical Examiner. Space for his/her approval number and date are
provided, In addition, space is provided for the name of the person obtaining telephone approval from the Medical Examiner and the date such
approval was obtained,
(NOTE: DO NOT HOLD UP FILING THE PINK COPY WHILE AWAITING MEDICAL EXAMINER APPROVAL.)
CEMETERY OR CREMATORY
Section D.
Required: Signature of Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton,); check the appropriate box to
indicate the method of disposition; fill in the date and place of disposition in space provided