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FAMILY/ESTATE/ORGANIZATION CONSENT <br />I, hereby <br />Family/Estate/Authorized Representative of <br />declare that I am duly authorized by the <br />to grant consent to <br />to submit the name of <br />for a request for honorary designation of a public street maintained by the City of Portsmouth. It is my <br />understanding that the name of the indicated individual or group is for "honorary" purposes only and does <br />not change the official name of the street. It is also understood that should the above name be approved by <br />the City Council, no further permission beyond this consent must be sought from the family/estate/entity <br />with respect to the name's selection for use by the City of Portsmouth. <br />Signature <br />Printed Name <br />Date <br />Authorized Family/Estate/Entity Agent: <br />Relationship to the Deceased Individual: <br />Agent's Address: <br />Telephone Number(s): <br />Email Address: <br />