Carlson, Florence M.I 28th
i THIS INDENTURE, Made this day of___Aug ist A. D., 19__.46,
between the City of Clearwater, Florida, a municipal corporation created and existing under the laws
1 of the State of Florida, party of the first part, and_ Florence M. Carlson , of the 1
County of Pinellas , State of FlOridB part _Y _._ - of the second part: ■
1 WITNESSETH : That the said party of the first part, for and in consideration of the sum of 1
! 80 • CC , to it in hand paid by the said part _._Y-. -__._ of the second part, the receipt whereof 1
i
! is hereby acknowledged, has, remised, released, and quit - claimed, unto the said part _Y of the !
! second part, and her 1
1 p heirs and assigns forever, all the right, title and interest, which the said 1
Iparty of the first part has in and to the following described lot, tract, or parcel of land, lying and being 9
1 in Pinellas County, to wit : The South one half _ of__- lot. __ 106. __Block __NI ne- (- 9 -) - -�- > w '" i
Clearwater Cemetery 1
1 TO HAVE AND TO HOLD the same to the only proper use, benefit, and behoof of the said
!
0 part Y of the second part her heirs and assigns forever.
! IN WITNESS WHEREOF, said City of Clearwater, a municipal corporation, has caused these
1
1 presents to be executed in its name by its Mayor Commissioner, by its City Manager, and to be at-
tested and its corporate seal affixed by its City Auditor and Clerk on this the day and
Y y year first
above written.
Signed, Sealed and Delivered
in the presence of us:
State of Florida,
County of Pinellas:
By
Countersigned:
CITY OF CLE'A' mss. ER, FLORIDA.
-"'"Gity Manager.
Personally appeared before me, Geo.R•Seavy,P.L.Hendrix
and Frank Cooley
City Auditor d Clerk.
to me well known to be the persons who
executed the foregoing instrument of conveyance in the capacity of Mayor Commissioner, City Man-
ager, City Auditor and 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 corporation, for .the uses and purposes therein expressed.
Witness my hand and official seal at Clearwater, Florida, this the _ _ 28th day of
August A. D.19 46,
(Seal)
i
Q4
Notary j. blic State of Florida.
My commission e .ires__4-28 1949•
1
quit -Claim Deed
FROM
CITY OF CLEARWATER,
FLORIDA
A Municipal Corporation
TO
Florence, ". ,Carlson
Dated
August 28th
Filed for record on
Recorded in ..
Book_._
19_ �6,
Clerk
DEEOI4G2 Pi r 279
THIS INDENTURE, Made thissixteenth day of September A. D., 19__3__
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 Florence M.Nelson
County of Pinellas
, State of Florida
, of the
, part_!-_ of the second part;
WITNESSETH: That the said party of the first part, for and in consideration of the sum of
$ 80.00
, to it in hand paid by the said party of the second part, the receipt whereof
is hereby acknowledged, has, remised, released, and quit- claimed, unto the said party of the
second part, and her heirs and assigns forever, all the right, title and interest, which the said
party of the first part has in and to the following described lot, tract, or parcel of land, lying and
being in Pinellas County, to wit: The South one -half of lot 1O6,-Block 9,Clearwater
Cemetery.
TO HAVE AND TO HOLD the same to the only proper use, benefit, and behoof of the said
part__jt of the second part her 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 at-
tested and its corporate seal affixed by its City Auditor and Clerk on this the day and year first above
written.
Signed, Sealed and Delivered
in the presence of us:
Nit
State of Florida,
County of Pinellas:
By
CITY OF CLEARWATER, FLORIDA.
Counters /gned,,:
AtteS
City Manager.
Mayor Commissioner.
City Auditor and Clerk.
Personally appeared before me, Herbert M.Brown, F.C.Middleton
and H.G. "Jingo to me well known to be the persons who
executed the foregoing instrument of conveyance in the capacity of Mayor Commissioner, City
Manager, City Auditor and 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 corporation, for the uses and purposes therein ex-
pressed.
Witness my band and official seal at Clearwater, Florida, this the sixteenth day of
September A. D. 19 53
(Seal)
Notary Public State of Florida.
My Commission expires
Quit-Claim Deed
From
CITY OF CLEARWATER,
FLORIDA
A Municipal Corporation
To
!
Florence M.Nelson
Route 1.Box 134.
Clearwater,Florida
Dated September 16th
19.53-
Filed for record on
&,'
Recorded in
"7433
_
Book Page
W. GILKERSONI
Clerk
ds of
Pinellas County.
TYPEJPRINT
114
PERMANENT
BLACK INK.
FILED MAR 0 7 2007
REGISTRATION DISTRICT NO.
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
CERTIFICATE OF DEATH
REGISTRAR'S NUMBER
124 -
STATE FILE NUMBER
FOR
INSTRUCTIONS
SEE HANDBOOK
I !
t. DECEDENT'S NAME (First, Mddle. Iasi)
Florence Martha Nelson
2. SEX
Female
_ .
3. DATE OF DEATH (Month, Day. VW
February 15, 2007
4. SOCIAL SECURITY NO.
5a. AGE - Last
r' Olsen)
5b. UNDER 1 YEAR
Sc. UNDER I LAY
6. DATE OF BIRTH (Month, Day, T11110
Jan. 21, 1923
7. BIRTHPLACE (Gay and State o Foreign Country)
Mt. Ephriam, New Jersey
DECEDENT
092 -12 -5189
WaTHS ° "S
''MR5 I 'n "ifts
vs 30a
w'' 211 fJa>f
B. WAS DECEDENT EVER IN
U.S. ARMED FORCES?
❑yes Me ❑Unk.
9a. PLACE OF DEATH (Check only ono)
HOSPITAL: xi Inpatient ❑ ERIOulpatient ❑ DOA
OTHER: ❑ Nursing Home ❑ Residence ❑ Other (SpeoYty)
9b. FACILITY NAME (11 not Oslianion, gam street and twmoer)
Cass Medical Center
9c. CITY, TOWN, OR LOCATION OF DEATH
Harrisonville
9d. COUNTY OF DEATH
Cass
10. MARITAL STATUS - Married, Never
Wid�o n1o. Ind. (° i)
11. SURVIVING SPOUSE'S NAME
(a wife, gne h l maiden name)
12a, DECEDENT'S USUAL OCCUPATION (Giro kind of
work corky run_ 9 est or rekHpe Iite. Da net use refined)
r
120. KIND OF BUSINESS OR INOUSTRY
Own Haase
0 13a RESIDENCE - STATE
Missouri
136. COUNTY
Cass
13c. CITY, TOWN, OR LOCATION
Harrisonville
13d ZIP COLE
64701
130. STREET AND NUMBER
801 E. Mechanic Street
131. INSIDE CITY LIMITS
2
lh Yea ❑ No
13g. YEARS AT PRESENT ADDRESS
2 °
If Under 5 ❑ 5 -9 ❑ 10 -19 ❑ 20 or more
$w
iu
zc
14. WAS DECEDENT OF HISPANIC ORIGIN
(Sparely No or t190 • e yes. speedy Cuban. MeriCen. Puerto Rican, etc.)
D
® No ❑ Yes specify:
15. RACE • American Indian. Black White. etc.
(Spar.•dy)
White
it DECEDENTS EDUCATION
(Sparely orgy MOWS( OOMPIefad)
ETerrtent,ry�emndary (0-12)
LL
College (1 -a a S.
17. FATHER'S NAME (First Mlle, Last)
1B. MOTHER'S NAME (Fast. Af kle, Marko, Surname))
Elsie Grundman
PARENTS Peter Blackman
19a. INFORMANT'S NAME (Type'Pr4u)
191. MAILING ADDRESS (Sheet and Number or Rural Route Member. Clly or Town, State. Zip Code)
801 E. Mechanic Street, Harrisonville, Mo. 64701
INFORMANT Mrs. Claudia Hutchinson
20a. BURIAL- CREMATION,
20b. DATE OF DISPOSITION
°%/;'
20c. PLACE OF DISPOSITION (Name of Cemetery, crematory. or
°" "°'°")
O'Neill Crematory
200. LOCATION (City et Town, State)
Peculiar, Missouri
DISPOSITION
Crem�abn
F�.h' 2007
21.91 TORE OF FUNERAL SERV CE LICENSEE OR
ON ACTING AS SUCH
.` .
v, t{�1•�
22a. N AND ADDRESS OF FACIUTY
Dckey Funeral Home
P.O. Box 432
Harrisonville, Missouri 64701
22b FUNERAL ESTA(iLISHMENT
LICENSE NUMBER
1448
3. PflT l -Ender Nth diseases, 0703(00. or complkbtione that caused the dealh. Do ru3 enter the made of dying, such as cardiac or respirato y arrest, shock. or heart failure.
List 0017 One 500310 at each Iota
IMMEDIATE CAUSE ♦ .. RESPIRATORY FAILURE 2° TO PNEUMONIA
(1 inaf 0,338000
condition ,.sufin
DUE TO (OR AS A CONSEQUENCE OF):
Approrlmate Inlerlral Between
Onset end Death
, 0
THIS IS A CERTIFIED COPY OF AN ORIGINAL DOCUMENT
(Do not accept if reproduced, or if seal impression cannot be felt.)
THE REPRODUCTION OF THIS DOCUMENT IS PROHIBITED BY LAW (sec. 193.245, 193.255, & 193.315 RSMo 2004.)
STATE OF MISSOURI
CITY OF JEFFERSON } SS I HEREBY CERTIFY that this is an exact reproduction of the certificate for the person named therein as it now appears in the permanent records of the Bureau of
Vital Records of the Missouri Department of Health and Senior Services. Witness my hand as State Registrar of Vital Records and the Seal of the Missouri Department of Health and Senior Services this date of
JU 082015
MO 580 -1241 (1 -12)
VS -804C
in death)
Sequentially psi
conditions, a any,
leading to immediate
UNDERLYING CAUSE
(di -sense or aWrY that
initialed events resulting
in deaf)!) LAST
b.
DUE TO (OR AS A CONSEQUENCE OF):
CAUSE OF
DEATH
DUE TO (On AS A CONSEQUENCE OF):
d.
PART e. Other significant condnlona contributing to death but not resulting in the wearying cause given it Pant.
•
2A. IF DECEASED WAS
FEMALE 10-40. WAS SHE
PREGNANT W THE LAST
90 DAYS?
1 2
❑ Yes ❑ No ❑ Unk.
25a. WAS AN AUTOPSY
PERFORMED?
1
❑ Yes i No
250. WERE AUTOPSY FINDINGS
AVAILABLE PRIOR TO
COMPLETION OF CAUSE OF
DEATH?
1 2
❑ Yes ❑ No
26. MANNER OF DEATH
E Natural ❑ Pending
Investigation
❑ Accident
❑ Suicide ❑ Could Rd) be
Determined
❑ Homicide
27a. DATE OF INJURY
(Month. Day. 1Wir)
27b. TIME OF
INJURY
M
27r.. INJURY Al" WORK?
t 2
❑ Yes ❑ No ❑ Unk,
27d. DESCRIBE HOW INJURY* OCCURRED
274. PLACE OF MJURY • Al Mme. farm st eel, Zack ry. endue
bAlaing, 010 (ap.clfy)
2TI. LOCATION (SYreet end Num Mr o R al gads N mbar. Gry o Town, S adia)
2p8a1. (.rl+vraly)
IOL CERTIFYING PHYSIGAN
❑ MEDICAL EXAMINEWCORONER
2110. To tM bsM d my knavledge, deadt accu 1 the t date and deco ofd duo to one causes) stated.
(S+gnature sad Ti(!e) ►
20c. DATE SIGNED
(Moser DIY Yea )
2 1 h- 2 Q
2811. THE Of DEATH
1:37 P M
29a. NAME AND ADDRESS OF CERTIFIER ( PHYSICIAN, MEDICAL EXAMINER OR CORON ) (Type or Pont)
Aaron L. Travis, D.O.
1620 E. Elm, Harrisonville, Mo. 64701
29b. MO. LICENSE NUMBER
105929
30. WAS CASE REFERRED TO MEDICAL EJ(AMINEWCORONER?
❑ Yes �No
31. NAME OF ATTENDING PHYSICIAN LF OTHER THAN CERTIFIER
(T1Te or Print)
32. REGISTRAR'S SIGNATURE
��
33. DATE RECEIVED BY LOCAL REGISTRAR
(Month. Day, Thar)
S41r -^ - •∎_ _ 0 i L () 7
, 0
THIS IS A CERTIFIED COPY OF AN ORIGINAL DOCUMENT
(Do not accept if reproduced, or if seal impression cannot be felt.)
THE REPRODUCTION OF THIS DOCUMENT IS PROHIBITED BY LAW (sec. 193.245, 193.255, & 193.315 RSMo 2004.)
STATE OF MISSOURI
CITY OF JEFFERSON } SS I HEREBY CERTIFY that this is an exact reproduction of the certificate for the person named therein as it now appears in the permanent records of the Bureau of
Vital Records of the Missouri Department of Health and Senior Services. Witness my hand as State Registrar of Vital Records and the Seal of the Missouri Department of Health and Senior Services this date of
JU 082015
MO 580 -1241 (1 -12)
VS -804C