HomeMy WebLinkAbout4-48-14Paid bY CEMETERY Receipt No. · ·~ ........... Dated ~ ...... .~.a. ~. , .~..~. %, .~..~..~.~.
List l'tic~ $ 400,00 M~ximum NO. Burial Spaces ...... 2
Net Paid $ .8/} 0.. 0.0 ........ Monument permitted .... F~l at, ............
Lots 13 & 14 Donald Rutherford Interred in Lot 14,
Blk. 48, Unit 4 5/l~/87(D,taehevemm~,~for~a~o~o~y)
NO.
1118
Marie Rutherford
504 S. Egret Circle
Barefoot Bay, Fl. 32958
(lliIl! of ebaslian.
(!lemelery Deei
NO.
THIS INDENTURE MADE ~ ./2nd ............. day of ......Ha.y ................................. A. D, 1S...8.7,
between ibc ~ty of Seb~tla~ a m~lci~ ~omt~n ~lstin~ ~der the laws of the State of Flor~ ea Or~tor and
.................................. ~ie..R~ker fo.r.d ........................................................................
504 S. Egret Circle, Barefoot Bay, Fl. 32958
ot ,he ~tr o~ .... ~$.~..~$~ .................... ..-t State af .............. Ei.o~.~ .............................
~ Gra~ WITNESSETH,
T~t the G,~tor for ~d
~owl~ge~ do~s by t~ ~I~ni ~ b~, ~fl, Iel~, ~nvey ~d ~ ~to the Gr~tee .... ~ ~. heirs, ~a[ ieple~nta~ves ~d as~s
· e fo~ow~g prope~y dt~led ~ Seba~ Indi.. ~er Cowry, Flor~a, t~wit:
~ of Lot(s) .......
Book 2, at p~e 6~ of
~ ~ River Co~ty, Flod~
To Have and to Hohi the same forever; prov/ded that said prope~y shall he used ~olely and exclusively for the interment of the human dead and shall
be used, kept and maintained at all times in a~-.ordance w/th the ~ules and re~uhtions, ordinances and resolutions of the City of Sebastian, Florida, hereto-
fore, now and hereafter adopted or provided for the government and operation of said cemetery. The conditions, restrictions and sequirements contained
in this instrument ~ be covenants rimming with the land. In the event of the fallme of the owner of any property situated w/thin ~ cemetery to ob-
serve and comply with iuch rules, r~gulat/ons, resolutions and ord/nanses and the conditions of the deed of conveyanc~ thereof then the titl~ of sudl owner
in and to said property shall termhlate and the same shall revert to file City of Sebastian, Flor/da.
IN WITNESS WH~I~OF, The said party of the fl~st part has caused this instrument to he executed in its name and on its behalf by its Mayor and
attested by its City Clerk and its corporate seal to be hereto affixed, the day and year lust above wtitten.
Signed, Sealed and Delivered
In th~ Presence oI~
STATE OF FLORIDA
COUNTY OF INDIAN' RIVER
'Name
Unit
Block
Lot
Date of Mark-out
Date of Burial
Time
Name of Funeral
Authorized by
STATE OF FLORIDA
r OF HEALTH & REHABII. i SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL-TRANSIT PERIVlIT
A, (Type or Print)
1. Name of First Middle Last DATE Month Day
Deceased , OF
DONALD B. RUTRER~ORD DEATH HAY T ~_ t 9R7
2. Place of Death City, Town or Location Name of (If neither, give street address) -
County Hosp. or
INDIAN RIVEE ROSELAND Inst.
3. Name of Medical ~ Physician
Year
HUMANA HOSPITAL-SEBASTIA~
Address
4. Funeral Home/
Direct Disposer
5. Check
Appro-
priate
Box
Certifier M. NASIR RIZW[, M.D. i--)Medical Examiner 7955 BAY STI~ET. ~ SEI{A~TIAN
Name Address
ST~UNK FUNERAL HOME, 1623 N. CENTRAL AVENUE., SERASTIAN
a [] The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
b [~ BEVERLy (REP, RRTARY) was contacted on K/! K_/87. He/she verified that
this death was fromDl{,natural. RTzwICauses' that there was no accident nor other external cause of death, and that
w, il comp eta and sign the medical certification of
6. Funeral Director/
cE]
medical certification.
was contacted on He/she verified that
, Medical Examiner, will complete and sign the
/ F
F la. Lic. No./Reg. No. DateSigned
BURIAL-TRANSIT PERM T ~ . . 1228-87-[90
I'ermlt NO.
Permission is hereby granted to dispose of this body.
[~ A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and
granted. If it cannot ~e filed within ~n~s time limit a "Funeral Director/Direct Disposer will be filed
with the Local Registrar of the County/in which death occurred. Report"
Registrar or '-~'/ · /'t* ~/~_ ~ Date
Sub-Registrar Signature~-]cJ/],,~-~ / F~-'~ ~
~/ Issue¢ MAY 15, 1987
AUTHORIZATION for CREMATION, DISSECTION or BURIAL--AT-SEA
Signature Medical Examiner Date.
or
Medical Examiner, , gave authorization by telephone to
Funeral Director/Direct Disposer. Date
The Medical Examiner's approval must be ~btained before disposa~ by any of the above methods. A waiting period of 48 hours after death
is required for all cremations,
Method of Disposition:
[] BURIAL [] STORAGE
[] CREMATION [] OTHER {Specify)
Signature of Sexton )
or Person-in-Charge }
CEMETERY OR CREMATORY
Place of Disposition
Date of Disposition
This permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton)
and returned within 10 days to the local County Health Department in the County where disposition occurred.
HRS Form 326, APR. 81
(replaces previous editions which may be used.}