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Home My WebLink About4-42-03Paid by CEMETERY Receipt No List price 800.00 Net Paid 800.00 Signed, Sealed and Delivered in the Presence of: STATE OF FLORIDA r'N INTV Ala T I IY v .aura.. J 7 Dated 3 (City of 'tbantiuu Trinettry Beth Maximum No. Burial Spaces Monument permitted (Data above this line for City Record only) Lots 1,2,3,4 Block 42 Unit 4 Stephen G.and /or 1261 Alice D. Harber POBox 202 Roseland,F1.32957 THIS INDENTURE MADE Thls 7th day or March between the City of Sebastian, a municipal corporation existing under the laws of the State of Florida, as Grantor and Stephen G. and /or Alice D. Harber Mailing: POBox 202, Roseland, F1. 32957 lit/ Me 949 .P.o tPma .c Fl,.. 32958 of the County of Indian River and State of Florida u Grantee, WITNESSETH: That the Grantor for and in consideration of the sum of 800 to it in hand paid, the receipt whereof is herewith ac- knowledged, does by this instrument grant, bargain, sell, release, convey and confirm unto the Grantee heirs, legal representatives and assigns the following property situated in Sebastian, Indian River County, Florida, to -wit: All of Lot(s) y; ?y,} ,Block, .412 UNIT 4 of Sebastian municipal cemetery as per Plat Number 1 thereof recorded in Plat Book 2, at page 65 of the public records in the office of the Clerk of the Circuit Court of St. Lucie County of Florida; said land now lying and being in Indian River County, Florida. To Have and to Hold the same forever; provided that said property shall be used solely and exclusively for the interment of the human dead and shall be used, kept and maintained at all times in accordance with the rules and regulations, 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 requirements contained in this instrument shall be covenants running with the land. In the event of the failure of the owner of any property situated within said cemetery to ob- serve and comply with such rules, regulations, resolutions and ordinances and the conditions of the deed of conveyance thereof then the title of such owner in and to said property shall terminate and the same shall revert to the City of Sebastian, Florida. IN WITNESS WHEREOF, The said party of the first part has caused this instrument to be 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 first above written. CITY OF SEBASTIAN, FLORIDA 064eict Q City Clerk Mayor NO. (City Seal) NO. 1261 A.D., 19 90 Name f `l-f Unit Y Block yZ Lot 3 Date of Mark -out Date of Burial Name of Funeral Home Authorized by /4 ,,Brie, yx ,n, 1/3/1/ liCtiNX CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT Name Mac bey v Date (o l I Initials White Dept. of Origin Yellow Finance Pink Applicant Time /(.'0. r s� e) 4271 Cash XCheck# 5(tCy Amount Paid No. 001001 208001 Sales Tax 001501 322900 Garage Sales 001501 341920 Copies/Bid Specs. 001501 341910 LDC /Code of Ordinances 001501 341930 Election Qualifying Fees 601010 343800 Cemetery Lots 14 Lot/Niche 3 Block 41 Unit 001501 343805 Cemetery Fees 1150 00 Total Paid /50 3Aes D. FLORIDA DEPARTMENT OF HEALT A. (TYPE) Name of Deceased 2. Place of Death County Indian River 6. Funeral Director/ B. b. Regislwarr or Subregistrar Signature c. LJ DI-1326, 8/97 (Obsoletes all previous editions) (Stock Number: 5740- 000 0326 -2) First Alice State of Florida, Department of Health, Vital Statistics APPLICATION FOR BURIAL TRANSIT PERMIT City, Town or Location Sebastian 3. Name of Medical Certifier Richard T. Penly__ n Medical Examiner POf Physician 4. Name of Funeral Home /Direct Disposal Establishment Strunk Funeral Homes Crematory 5. Check a. Appropriate Box Middle Last D. Harber Date Month Day Year of Death 12/31/2010 Name of (If neither, give street address) Hosp. or Inst. 949 Potomac Avenue, Sebastian Address Phone Number 1265 36th Street Vero Beach, Fl 32960 Address Fla. Lic. No. /Reg. No. 1623 N. Central Avenue Sebastian, FL 32958 F041870 772/589 -1000 0 The medical certification has been completed and signed. A completed certificate of death accompanies this application. medical certification of cause of death within 72 hours. Signature, t 0 itinebr n01 Approval Number: Date OCREMATION OTHER (Specify) Signature of Sexton or Person -in- Charge 1(0./e6 Date Date Certificate Issued: 12/31/2010 c. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA Distribution: White: Cemetery or Crematory Yellow: Funeral Director or Direct Disposer Pink: Local Registrar 772/567 -6340 Phone No. (Area Code) Joan was contacted on Janaury 3, 2011 He /she verified that this death was from natural causes, that there was no accident nor other external cause of death, and that Ricahrd T. Penly, M.D. will complete and sign the medical certification of cause of death within 72 hours. was contacted on He /she verified that Medical Examiner, will complete and sign the F.E. No. /Reg. No. Date Signed F044048 01/03/2011 BURIAL TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No. 1228 -10 -0788 A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has been contacted by the funeral director and will not be able to complete the medical certification of cause -of -death section of the death certificate within 72 hours. No extension of time for filing the death certificate has been requested. Due: 01 /04/2011 Medical Examiner, 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 (?//elfi Method of Disposition: Place of Disposition .5E/34s/i `r' ��.C� BURIAL STORAGE Date of Disposition /s This permit must be endorsed by the Sexton or person -in -ch rge (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. FUNERAL HOME: ADDRESS: PHONE FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY 5 ion SEBASTIAN HOME Oi PIM For information contact: Kip Kelso Cemetery Sexton Sebastian Municipal Cemetery (772) 589 -2545 City Clerk's Office City Hall, 1225 Main Street Sebastian, FL 32958 Office (772) 388 -8215 or 388 -8214 Fax: (772) 589 -5570 (Check One) --K OPEN BURIAL LOT Lot Block y,. Unit 7 _OPEN CREMAINS LOT Lot Block Unit —OPEN COLUMBARIUM NICHE Niche Block Unit BURIAL DATE AND SERVICE TIME: /A —X /-"e9 FOR DECEASED: /9 c Name Name 40' Q Ce tery V. NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership) Date W Signature Date I certify that I have determined the ownership of the above described site that all site fees and administrative fees have been paid and authorize opening of same NAME AND SIGNATURE OF LICENSED FUNERAL DIRECTOR. I /,1 Name SignatUre Date Cemetery Sexton Certification: I certify that I have checked the ownership information by viewing the owner's deed and confirming with Clerk's office and that all fees have been paid This form to be provided to Clerk's Office by Sexton for permanent record upon completion.