Moore, Patsy Ann RobertsDate: / as / . -oi5_
Cemetery Call Work Sheet
Funeral Home / Monument Company:
�0 Orre-
Contact Name: Pw -1sy P P./ -' tS Tel. #: -741- '1'4'7- I I Tk Fax #:
/ . tvW ore.
Reason for call: Staking Request (Interment/Disinterment)
4
✓Affidavit (Burial Rights) -1GLk Lo-t-
Monument (Marker) being placed (No fee for staking of monument)
For:
Block Lot Space
Date: / / Time:
(Send email to P &R)
Verifying Burial space
Other reason:
******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Interment: (One full burial and one urn, or two urns per space)
Full Burial
Owner of Plot:
Deceased Name:
Urn Space
Block Lot Space
Date of Birth: / / Date of Death / /
Date of Burial: / /
Time: am /pm
$30.00 Staking Fee (Funeral Home) - received on: / /
Copy of permit emailed to Mark Tokar, cc: Cherise Sarnoff /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 11/24/14
GQ X� a01,co y
Status of Block: 2 Lot: 4 as of 01/22/2015
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED
1 FULL DUKES HELEN 9/3/1908 06 / 08 / 1914 6/8/1914
2 FULL DUKES AMADA 3/7/1872 04 / 11 / 1938 4/11/1938
5 FULL UNKNOWN 1/1/1901 01 / 01 / 1901 1/1/1901
6 FULL BOLEY ELVIRA D 10/30/1853 04 / 11 / 1890 4/11/1890
7 FULL WILLIAMS W H 2/19/1819 12 / 20 / 1908 12/20/1908
8 FULL WILLIAMS ELIZABETH E 2/14/1825 04 / 04 / 1890 4/4/1890
9 FULL ROBERTS HELEN W 9/16/1852 05 / 19 / 1941 5/19/1941
10 FULL ROBERTS TOM 11/2/1857 02 / 03 / 1930 2/3/1930
11 FULL ROBERTS ADIN H 11/7/1907 04 / 24 / 1966 4/28/1966
12 FULL UNKNOWN 1/1/1901 01 / 01 / 1901 1/1/1901
13 FULL UNKNOWN 1/1/1901 01 / 01 / 1901 1/1/1901
14 FULL UNKNOWN 1/1/1901 01 / 01 / 1901 1/1/1901
15 FULL BARNES HAROLD S 9/19/1895 05 / 25 / 1970 5/28/1970
16 FULL BARNES ANNIE L 12/15/1899 06 / 15 / 1990 6/18/1990
17 FULL COLLINS FRANCES E 2/29/1924 07 / 07 / 2000 7/12/2000
18 URN DUPPER RICHARD 1/1/1901
18 URN DUPPER DOROTHY 1/1/1901
19 FULL DUPPER HAROLD W 10/25/1952 01 / 02 / 1988 1/8/1988
24 FULL LONDON FREIDA M 5/23/1923 08 / 14 / 2006 8/21/2006
25 FULL SUMMERFORD MYRTLE 6/1/1902 01 / 03 / 1996 1/6/1996
26 FULL LONDON LAURA A 1/1/1904 01 / 01 / 1936 1/1/1936
27 FULL ROBERTS C E 1/1/1875 01 / 01 / 1943 1/1/1943
28 FULL ROBERTS MARY A 1/1/1876 02 / 03 / 1964 2/3/1964
29 FULL BARNES WILLIAM N 1/1/1871 01 / 01 / 1946 1/1/1946
30 FULL BARNES EMMA S 1/1/1874 01 / 01 / 1943 1/1/1943
31 INFANT BARNES INFANT 3/28/1907 03 / 28 / 1907 3/28/1907
32 FULL BARNES MEPHARMA 11/21/1868 03 / 31 / 1890 3/31/1890
33 FULL BARNES LAURA 11/28/1846 11 / 28 / 1903 11/28/1903
34 FULL BARNES T J 1/12/1846 09 / 05 / 1877 9/5/1877
Page 1 of 2
PERMIT
0
0
0
0
0
0
0
0
498
0
0
0
765
1868
2448
0
0
1725
2570
2243
0
0
334
0
0
0
0
0
0
INTERMENTS:
SPACE BURIALTYPE DECL DECF DECM BIRTH DEATH INTERRED PERMIT
35 URN BARNES DWIGHT W 10/7/1904 01 / 22 / 1985 2/2/1985 1595
35 URN BARNES MARION N 12/10/1909 01 / 06 / 1996 1/20/1996 2246
37 FULL HARRIS RUPERT 10/10/1892 09 / 07 / 1972 9/9/1972 930
38 FULL HARRIS LONA BARNES 7/29/1898 02 / 28 / 2001 3/3/2001 2472
39 FULL BOLEY BYRON K 5/30/1889 07 / 17 / 1915 7/17/1915 0
40 FULL SUMMERFORD LEON L 1/1/1901 05 / 31 / 1972 5/31/1972 919
41 INFANT ROBERTS IDA L 1/1/1899 01 / 01 / 1904 1/1/1904 0
42 INFANT ROBERTS RENA C 1/1/1897 01 / 01 / 1897 1/1/1897 0
42 INFANT ROBERTS JOHN W 1/1/1896 01 / 01 / 1896 1/1/1896 0
DISINTERMENTS FROM SPACE:
No Matching Records
REINTERMENTS:
2 FULL DUKES AMADA 04 / 11 / 1938 03 / 07 / 1872 04 / 11 / 1938 06 / 08 / 1992
Vc&cc +:
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Page 2 of 2
LaCosse, Judith
From: LaCosse, Judith
Sent: Tuesday, February 03, 2015 8:26 AM
To: 'Pmoorefedx @aol.com'
Subject: RE: Clearwater Municipal Cemetery Affidavit
Ms. Moore,
Thank you for your reply and we appreciate your kind words !!
Have a nice day !!
Judith LaCosse
Staff Asst
City of Clearwater
ORLS Dept.
727-562-4093
From: Pmoorefedx@aol.com [mailto:Pmoorefedx@ aol.com]
Sent: Tuesday, February 03, 2015 12:06 AM
To: LaCosse, Judith
Subject: Re: Clearwater Municipal Cemetery Affidavit
Judith,
Sorry for not responding to this email sooner. My computer crashed. I have Carbonite on it, so my computer rep
was able to resurrect almost all of my information.this evening.
To answer your question, you got the information about my grandfather correct. In fact I am amazed at your
complete and accurate full names and relationships listed on the Affadavit.
Although I will not be able to be buried as close to my Grandfather as I had wished, I am happy (VERY happy) and
cannot thank you enough for all your help. Had I been more aggressive many years ago, when I tried to learn
what I needed to do, there would have been more burial space options for me.
FYI, I have completed my information on the Affadavit & fulfilled the Notary requirements at my bank. It has been
forwarded via mail to my brother. I plan to be at home as much as possible when my mail is usually delivered in
hopes to prevent the possibility of it getting it folded or damaged in any way, when my brother returns it. See
you soon with the completed document <smile >.
i am so proud to know we have employees like you working for our City. . My time with you both was a joy & not
stressful in the least.
MY GRATITUDE TO YOU AND NICOLE ABOUNDS, Patsy Ann Roberts Moore
In a message dated 1/22/2015 3:27:43 P.M. Eastern Standard Time, Judith .LaCosse(amyClearwater.com writes:
Hello Ms. Moore,
I'm in the process of revising your affidavit giving you interment rights in the Clearwater Municipal
cemetery.
1
I didn't want you to think that we have forgotten. Nicole is out this afternoon so tomorrow I will have
her take a look at the affidavit before we send it to you for review.
I do have a couple of questions:
was the owner, Captain Tom Roberts, your great - grandfather ?
and do you wish to have your brother's name on the affidavit as well, if so, please provide his name.
Thank You ! !
Judith LaCosse
Staff Asst
City of Clearwater
ORLS Dept.
727 - 562 -4093
2
LaCosse, Judith
From: LaCosse, Judith
Sent: Thursday, January 29, 2015 10:44 AM
To: 'pmoorefedx @aol.com'
Cc: Sprague, Nicole
Subject: Clearwater Municipal Cemetery Affidavit
Attachments: Affidavit - Moore.doc
Importance: High
Tracking: Recipient
'pmoorefedx@aol.com'
Sprague, Nicole
Read
Read: 1/29/2015 2:15 PM
Ms. Moore,
Enclosed please find an affidavit prepared for your review assigning you interment rights in Block 2, Lot 4, Space 23.
If you're in agreement with this affidavit we need your signature and your brother's signature, and it needs to be notarized.
Please include address information as well.
You may return the completed affidavit to my attention to the address below. We will update our records to reflect this
information.
City of Clearwater
Official Records & Legislative Services Dept.
112 S. Osceola Ave.
Clearwater, FL 33756
Sincerely,
Judith LaCosse
Staff Asst
City of Clearwater
ORLS Dept,
727 - 562 -4093
1
AFFIDAVIT
STATE OF FLORIDA)
COUNTY OF PINELLAS)
I, Patsy Ann Roberts Moore, the undersigned, do hereby attest that I am the descendant
of Captain Tom Roberts, my grandfather's brother, and the original plot owner of the City of
Clearwater, Florida cemetery property described as Block 2, Lot 4 which is a forty two space lot
and currently consists of seven unused spaces, 3, 4, 20, 21, 22, 23 and 36. I am the daughter of
Claude Chestine Roberts and Pauline Courson Roberts. Claude Chestine Roberts was the son of
Claude Eugene Roberts and Mary Alice Crumpton. Claude Eugene was the brother of Captain
Tom Wesley Roberts.
1, as Captain Tom Roberts' heir, have a right to be buried in this plot. This document
assigns interment rights in Block 2, Lot 4, Space 23 to myself.
I further 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 /PHONE
Patsy Ann Roberts Moore Street Address
City/State /Zip
Thomas Wayne Roberts Street Address
(Brother of Patsy Ann Roberts Moore)
City/State /Zip
SWORN TO and subscribed before me this day of by
who produced identification in the form of
and who did /did not take an oath.
Notary Public
My commission expires:
SWORN TO and subscribed before me this day of by
who produced identification in the form of
and who did /did not take an oath.
Ors t 4 rj-�-z
Notary Public
My commission expires: