Rogers, Phyllis RayeDate: 1° / � /
Funeral Home / Monument Company:
Contact Name:
Reason for call:
Cemetery Call Work Sheet
044-4) T. #: 74'7- 3c(/ 53 Fax #:
Staking Request (Interment/Disinterment)
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Affidavit (Burial Rights) D-o lLc.-viLae) GA 3 °/344
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Monument (Marker) being placed (No fee for staking of monument)
For: re./ .# 44 3- a-Fio13
Block ^ Lot Space
Date: / / Time:
(Send email to P &R)
VVerifying Burial space SIO 1/ 5 - 5P I
Other reason: ►GIs. 8 tt ece_
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Interment: (One full burial and one urn, or two urns per space)
Full Burial
Owner of Plot:
Deceased Name:
Block Lot Space
Date of Birth: / / Date of Death / /
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Date of Burial: / / Time: am /pm
$30.00 Staking Fee (Funeral Home) — received on: / /
Copy of permit emailed to Marco Ortega, cc: Mark Tokar /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
Revised 10/31/12
1°A-1/14 ff; Lavi . -
i''�s. PL 5
OFFICIAL RECORDS AND
LEGISLATIVE SERVICES
October 9, 2014
CITY OF CLEARWATER
Ms. Phyllis Raye Rogers
197 Bakersbridge Circle
Douglasville, GA 30134 -5049
POST OFFICE Box 4748, CLEARWATER, FLORIDA 33758-4748
CITY HALL, 112 SOUTH OSCEOLAAVENIIE, CLEARWATER, FLORIDA 33756
TELEPHONE (727) 562 -4090 FAx (727) 562 -4086
Re: City of Clearwater Municipal Cemetery
Block 7, Lot 45, Space 4
Dear Ms. Rogers:
I received a call from your aunt, Betty Smith, regarding the above cemetery plot. She
mentioned that you are the sole descendant of Ray Touchton, your father, who is the owner
of spaces 1 -4 in Block 7, Lot 45. Space 4 is currently vacant.
Enclosed please find an affidavit prepared for your review assigning you the interment rights
in Block 7, Lot 45, Space 4. I'm also enclosing other pertinent information regarding this
plot.
If you're in agreement with this affidavit, please sign and have it notarized. Please return it
to my attention in Official Records and Legislative Services, and we will update our records
to reflect this information.
Sincerely,
I.LL 'Jct.
dith LaCosse
Staff Assistant
Enclosures
"Ea AL EMPLOYMENT AND AFB lRM:cnvr ACTION ENIMM.ovr,R"
AFFIDAVIT
STATE OF FLORIDA)
COUNTY OF PINELLAS)
I, Phyllis Raye Rogers, the undersigned, do hereby attest that I'm the
descendant of Ray Touchton, my father, who is buried in Block 7, Lot 45, Space 3. My
father is the owner of Block 7, Lot 45, Spaces 1 through 4 in the Clearwater Municipal
Cemetery. Space 4 is currently vacant.
Per the City of Clearwater Rules and Restrictions the maximum capacity of a
space is two burials provided at least one person is cremated or two cremated remains.
Please take this affidavit as your authority to assign interment rights in Block 7, Lot 45,
space 4 to myself.
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 ADDRESS
Phyllis Raye Rogers
197 Bakersbridge Circle
Douolasville, GA 30134 -5049
SWORN TO and subscribed before me this day of
by Phyllis Raye Rogers who produced identification in the form of
and who did /did not take an oath.
Notary Public
My commission expires:
Status of Block: 7 Lot: 45 as of 10/09/2014
1
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED
I FULL CARTER DEWITT T 10/3/1887 10 / 26 / 1937 10/26/1937
2 FULL CARTER HETTIE A 1/17/1893 03 / 10 / 1975 3/11/1975
3 FULL TOUCHTON RAY 5/20/1915 08 / 26 / 1937 8/26/1937
DISINTERMENTS FROM SPACE:
No Matching Records
REINTERMENTS:
No Matching Records
Page 1 of 1
PERMIT
0
1074
0
•
RANE
_i Cemetery
a File
Transaction
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Print Burial Permit
Good Afternoon? Today is Thursday. October 9, 2014
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Notes
Search Old Locations
Print /View Lot Status
Monthly Memo
Disinterments
Deceased by Location
Alphabetical List of
Deceased File
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p- rmits_l•:':st-BY
Location.
PRBuria'
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ECemetery Tracking System - View Lot Profile
Block: 7 Lot: 45
Profile Summary
Nnce feedkacif{µ
You are logged in as ludith.LaCosse
;Click 'View Assigned' to view interment details. If more than one individual is interred in a space, a second grid will appear
below, displaying all of the individuals assigned to the space. Click 'View' on the second grid to view the interment details of
that individual.
IWEST SIDE OF MYRTLE AVENUE
Owner First
Owner Middle
Max Interred
Total Assigned
Interred
2
TOUCHTON
TOUCHTON
RAY I
RAY
1
1
1 11
View Assigned
1 11
View Assigned
3
TOUCHTON
RAY 1
1
1 i 1
View Assigned
4
TOUCHTON
RAY
0
0 10
1
Vlew_f354gf_ °C1„
Updated on Tuesday, January 06, 2009
Horne I Feedback I Departments 1 Contacts 1 Forms
1
I Ton of page )
October 17, 2014
Ms. Phyllis Raye Rogers
197 Bakersbridge Circle
Douglasville, GA 30134 -5049
Re: City of Clearwater Municipal Cemetery
Burial plot: Block 7, Lot 45
Dear Ms. Rogers:
Enclosed please find another affidavit assigning interment rights in the above burial plot to
you or other family members.
Please review this affidavit and if you're in agreement, please sign and have it notarized.
Please return it to my attention in Official Records and Legislative Services, and we will
update our records to reflect this information.
I will give you a call again to verify that you received this correspondence.
Sincerely,
Judith LaCosse
Staff Assistant
Enclosures
AFFIDAVIT
STATE OF GEORGIA)
COUNTY OF )
I, Phyllis Raye Rogers, the undersigned, do hereby attest that I am a descendant
of Ray Touchton, my father, who is buried in Block 7, Lot 45, Space 3. My father is the
owner of Spaces 1 through 4 of this burial plot in the Clearwater Municipal Cemetery.
Below is the current status of this burial plot, Block 7, Lot 45:
Space 1 = full burial of Dewitt T. Carter
Space 2 = full burial of Hettie A. Carter
Space 3 = full burial of Ray Touchton
Space 4 = this space is currently vacant
Please take this affidavit as your authority to assign interment rights in this burial plot to
myself or other family members. I understand that the maximum capacity of a space is
two burials provided at least one person is cremated per the City of Clearwater Code of
Ordinances.
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 ADDRESS
Phyllis Raye Touchton Rogers
197 Bakersbridge Circle
Douctlasville, GA 30134 -5049
SWORN TO and subscribed before me this day of ,
by Phyllis Raye Touchton Rogers who produced identification in the form of
and who did /did not take an oath.
Notary Public
My commission expires: