Johnson, SandraDate:
/ I / 0-00
Cemetery Call Work Sheet
Funeral Home / Monument Company:
h4C/'a. c?o r, n s� n Tel. #: 7� it"c' - ( Fax #:
Contact Name: S �
tv .... -t•Q : d ar.cte e lag c°_ ►vt,CL
Reason for call: Staking Request (Interment/Disinterment)
Affidavit (Burial Rights)
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: t•k^ e.1i4"'c U r1 bwu c,Q Sr(fizA
Y
8,c 0 c k j it Lot's 4,0 v b ._
******************************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Interment: (One full burial and one urn, or two urns per space)
Full Burial Urn Space
Owner of Plot:
Deceased Name:
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
CONTRACT TO PURCHASE CEMETERY SPACE
THIS CONTRACT, made and entered into this '5C: day of
OCk0bei\ 20 b1 , between the City of Clearwater as "GRANTOR" and
Sandra F. Johnson , whose mailing address is 1394 S. Hil!crest Ave. ,
Clearwater, FL 33756 , of the County of Pinellas, State of Florida,
as "PURCHASER ":
WITNESSETH: That in consideration of the mutual promises and
covenants herein contained, and other valuable considerations, the Grantor
agrees to sell and the Purchaser agrees to buy the following described space:
Block 14 , Lot, 406 , 1-0.7 (Urn Spaces) , Clearwater
Cemetery, as recorded in Plat Book 60, Page 30, Public Records of Pinellas
County, Florida.
PURCHASE PRICE
RECORDING FEE
DOC STAMPS
$ 125.00 per urn = $250.00
$ 10.00 (+ $8.50 add'I page)
$ 2.10
Total balance due is $ 262.10 . In the event of default in the balance due, the entire sum may be immediately declared due
in full. Failure of the purchaser to make said payment shall entitle the Grantor to retain all proceeds theretofore paid, as liquidated
damages, and may also retain title to any part or portion of said property which has not been used for grave space, and thereupon this
contract shall become null and void.
NO SPACE SHALL BE USED AS A BURIAL SITE UNTIL THE CONTRACT HAS BEEN PAID IN FULL.
THE PURCHASER FURTHER AGREES to abide by all rules and regulations governing the use and maintenance of space(s)
in Clearwater Cemetery. This contract shall not be assigned nor shall any grave space sold hereunder be transferred without the
written consent of the City of Clearwater.
The obligations and benefits under this contract shall extend to the personal representatives and heirs of the Purchaser and
the successors of the City.
IN WITNESS WHE OF, said parties have set their hands and seals the day and year first above written.
ctn CIV
PURCHASER(S)
(Witness as to Purch er)
it
// c St- E,' Ice 4.5 Z �
address (please print) 1 ; % -3 3-7 b
Attest:
Nicole Sprague, De.uty C
Approved as to form:
Paul Richard Hull, Assistant City Attorney
address (please print)
CITY OF CLEARWATER, FLORIDA
By: ctu 4 t//141ban.d r.•
Willi m B. Horne, City Manager
COUNTERSIGNED:
By: CE.4244"\Cf \t1
George N. Cretekos, Mayor
( , 33iSZ
STATE OF FLORIDA )
COUNTY OF PINELLAS)
�'►�� -.1‘)c rAbo424) r9 +
Before me personally appeared W;Ilia, , D. I k, the1Gity Mana er of the above named city, who acknowledged that he
executed the foregoing instrument. He is personally known to me and did not take an oath.
WITNESS my hand and official seal this (Dday of AJOJ'enAmar, 201 P
(SEAL)
4:1,P`�0 SANDRA HARRIGER
MY COMMISSION # FF930375
'471/ ,, EXPIRES: January 04, 2020
Before me personally appeared George N. Cretekos, the Mayor of the above
the foregoing instrument. He is personally known to me and did not take an oath.
%?' A/OVein 6
WITNESS my hand and official seal this day of �- , 20 /r .
(SEAL)
CONTRACT. DOC
,s4101/14, Notary Public State of Florida
.
Patricia A Kuligowski
eg My Commission GG 131393
of Expires 10/20/2021
rint name:
named city, who acknowledged that he executed
Notary Public
Print nam
9700 -0027
Rev. 10/17
CEMETERY DEED
KEN BURKE, CLERK OF COURT
AND COMPTROLLER PINELLAS COUNTY, FL
INST# 2017351699 11/16/2017 03:27 PM
OFF REC BK: 19844 PG: 1742 -1742
DocType:DEED RECORDING: $10.00
D DOC STAMP: $2.10
THIS INDENTURE made this 30th day of October , 2017, between the City of
Clearwater, Florida, a municipal corporation as Grantor and Sandra F. Johnson , whose
mailing address is 1394 S. Hil!crest Ave., Clearwater, FL 33756 , of the County
of Pinellas, State of Florida, as Grantee:
WITNESSETH: That the said Grantor, for and in consideration of the sum of $262.10 in hand paid by the said Grantee, the
receipt whereof is hereby acknowledged, has remised, released and quit - claimed unto the said Grantee, and their heirs forever, all the
right, title and interest, which the said Grantor has in and to the following described parcel of land, lying and being in Pinellas County,
State of Florida, to wit: Block 14, Lots 406 & 407 (Urn Spaces) , Clearwater Cemetery, as recorded in Plat Book 60, Page 30,
Public Records of Pinellas County, Florida.
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 only for cemetery purposes as human burial sites and is
subject to such other rules and regulations the City of Clearwater may adopt pertaining to use of said property.
TO HAVE AND TO HOLD the same to the only proper use, benefit, and behoof of the said Grantee and their heirs and assigns
forever.
IN WITNESS WHEREOF, said Grantor has caused these presents to be executed in its name by its Mayor, by its City Manager,
and to be attested and its corporate seal affixed by the City Clerk on the day and year first above written.
Countersigned: CITY OF CLEARWATER, FLORIDA
_ eOrtc r\ CrAtt05
George N. Cretekos, Mayor
STATE OF FLORIDA )
COUNTY OF PINELLAS)
Before me, the undersigned, personally appeared George N. Cretekos, the Mayor of the City of Clearwater,
known to be the person who executed the foregoing instrument and acknowledged the execution thereof to be her fre
for the use and purposes herein set forth.
WITNESS my hand and official seal this / day of /VovC,n , 2017.
By. 4.h evaA *Y5 fo
W m B Horne, II, City Manager
LbAttest:' .lVb
Nicole S ra ue, Deputy ty CI
>t'4 Notary Public State of Florida
�
Patricia A Kuligowski
y c My Commission GG 131393
14,„ of Expires 10/20/2021
- // Not ry Public
Print/type name: il`17�GrciA
STATE OF FLORIDA )
COUNTY OF PINELLAS) 3=111S,,1ve r +� 71 R '
Before me, the undersigned, personally appeared , the City Manager of the City of Clearwater, Florida, to me
well known to be the person who executed the foregoing instrument and acknowledged the execution thereof to be his free act and
deed for the use and purposes herein set forth.
WITNESS my hand and official seal this �D� d y of NOVQ,tNINALr 2017.
Approv `i. s to form.
Paul Richard Hull, Assistant City Attorney
CEMETERY DEED.DOC
RETURN TO: Official Records & Legislative Services
P. O. Box 4748, Clearwater, FL 33758
Notary Public
Print/type
name. i'f r
_° o,, SANDRA HARRIGER
pi MY COMMISSION Jr FF930375
+r. .," EXPIRES: January 04, 2020
9700 -0026
Rev. 7/17
SANDRA F JOHNSON
DEANNA WILLIAMS
1394 S Hillcrest Ave
Clearwater, FL 33756
727 - 442-0470
PAY TO THE
ORDER OF
63- 4661631
$ ZG2r 10
•Ibb
DOLLARS
A REGIONS
FOR C rvi e (Off
I:063 /04668i: O /4214988611.02 L55
lirland Pate