HomeMy WebLinkAbout4-45-02 _ .400,00 '- '
t.u,,t i'd. co ~ .................. Maximum No. Burial Spaces ..... ~. ...........
Net Paid $ .~ 0.0 ,.0 ~ ........ Monument per'trod, o T.. E~ a 12.. T. ........
Agnes Green Interred Lot 2 12/22/87
(Data above thh U~e for C~ty l~,cord ouJy)
Lots 1 & 2
NO.
BLK.45,UN. 4
Harry S. Green,
3745~ Main St.
Sebastian, Fi.
1180
Jr.
Ig ll! of ebaslian
OIemeIery II e eil
NO.
the Cun~tr o~ ...Zndian..Ri;.r ..................... ~-] State of ......~.~.o..r.~.{~ ......................................
Grantee, WITNESSETH ~
That the Grantor fo~ and in consideration of the sum of $ . .~.0..0....0..0. ............... to it in hand pakl, the r~ceipt whereof is h~rewith am
knowledgad, does by this instrument gra~t, ba~gaih, s~ll, rel~a~, convey and confmn unto the Grantee ....h..~.~.. l~ks, legal rcpresantafives and asdgns
All of Lot(s) .~.. &. ~ Block, .~ ..... UNIT . .~ ........... of Seb~tlan muni,qpal cemetery as per Plat Numhe~ 1 thereof recorded in Plat
To Have and to HaM the ~me fomvei; provided that said plopetry shall be used ~oiely and exclusively for the interment of the hum~ dead and shall
be used, kept and maintained at all Braes in accordance with the roles and regulations, ordinan~s and re~ointions of tl~ City of Sebastian, Florida, hereto-
fore, now and hereafter adopted or ptovic~d fei tile government and operatk>n of said c~metery. The conditions, restrictions and ~quirements contained
in this in~rumcnt shall be covenants running with the la~d. In the event of the failure of the owner o£any property situated within said cem~tary to o1~
~erve and comply with ~¢h rules, regulations, ro~olutions and ordimmces and the comiitiorts of the deed of conveyance thereof then tl~ ritla of such owner
in and to sa~d prop~ty ~ terminate and the same shall revert to the City of Sebastian, Florida.
IN WITNESS WHEREOF, The ~aid party of th~ fff~t part has caused this instrument to be executed in its nam~ and on its behalf by its Mayor and
attestad by its City Clerk and its corporate seal to be hereto aff'Lxed, the day and yea~ £t~st above written.
. ~/ City ~lerk
Signed, Sealed and Delivered
......... ./.... ..........
STATE OF FIX)RIDA
COUNTY OF INDIAN RIVER
Unit
Block
Lot 2',
Date of Mark-out
Date of Burial
Name ol Funeral Home
Authorized by
Unit
Block
Lot ~-'
Date of Mark-out
Date of Burial
Name of Funerat Home
Authorized by ~
GREEN, HARRY S.,.Or DEED NO.
3745½ Main St.
Sebastian, Fi. 32958
1150
Lots 1 & 2
Blk.45, Un.4
Agnes Green interred 12/22/87 Lot 2
Pmid by CEMETERY Receipt No....4.~.8· ......... Dated. 12/21/87
List P~ice $ 400.00 M 2
.................. axJmum No. Burial S~c~s .................
Net Paid $ J~ 0.0 ~.0 [l ........ Monument permitted...".. F.]-~, [1...'% ........
Agnes Green Interred Lot 2 - 12/22/87
(Data above ii,is line for City Record only)
Lots 1 & 2
NO.
BLK.45,UN.4
11 0
Harry S. Green, Jr.
3745½ Main St.
Sebastian, FI.
CITY OF SEBASTIAN
~1501 3~00 ga~e Sal~
White - OGpt, of O~gin · Yellow -Flnanee · Pink. Applicant
STATE OF FLORIDA
[PARTMENT OF HEALTH & RENABILI1 ~E SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL-TRANSIT PERMIT
A. __(Type or Print)
1. Name of First
Middle Last DATE Month Day Year
Deceased AGNES ELEANOR GREEN OF
DEATH 12 - 20 - 87
2. Place of Death City, Town or Location
County Name of (If neither, give street address) ~
INDIAN RIVER Hosp. or
Inst. HUMANA HOSPITAL-SEBASTIAN
3. Name of Medical
ROSELAND
[] Physician Address Phone Numoer
Certifier NOOR H-ERC~T, M.D. [] Medical Examiner 1388.5 OS.If 1 /SEBASTIAN~ FL 567-2332
4. Funeral home/ Name __
Address Phone Numaer [Area Code)
~rSTRUNK FUNERAL HOME 1623 N. CENTRAL AVENUE SEBASTAIN, FL 305-589-1000
5. Check a [] The medical certification has been completed and signed. A completed certificate of death accompanies
Appro-
Box b
and sign me medical certification of cause of death.
6. Funeral Director/
this application.
. DR. MF~R ~J~NT
was contacted on 12/21/87 within 48
hours after Death. He/she verifmd that this Death was from natural causes, mat there was no accident nor
omer external cause of dean, and that HE
w[Jl complete
was COntacted on _ . He/she verified that
· Medical Exammer, will complete and sign the
Fla Lic. No./Reg..Ne~.
Date Signed
/
B. BURIAL-TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228-87-478
[] A five Day extension of time for filing the death certificate (exclusive of weekends) has peen requested and grantco. If it cannot ~e flied
within this time limit, a 'Funeral Director/Direct Disposer Report" will be filed with the Local Registrar of the County in which neath oc-
curred,
[] No extension of time for filing th~eath certificate~equest~.
Registrar or /tJ~ ~J',, C
Sub-Registrar Signature ~ , (~~~_ Date /'~ /~,/,o~ Date Certificate
- - Issued. ~ Due:
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL--AT--SEA
Signature
or , Medical Examiner Date
Medical Exam nor,.,
, gave authorization by telephone to
Funeral Director/Direct Disposer. Date_
The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting period of 48 hours after
death is required for all cremations.
CEMETERY OR CREMATORY
Method of Disposition:
[] BURIAL [] STORAGE
J-'] CREMATION ['-] OTHER (Specify)
Signature of Sexton )
or Person-in-Charge }
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, May 86 (Replaces Apr 81 edition which may be used)
(Stock Number: 5740-000-0326-2J