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Paid by CEMETERY Receipt No. . . . . . . 60.0. . .. . Dated. . .1 Z /l2.L a 9. . . . . . . . .. . . . . . Lo t s 9 & 10
List Price s.. .~.OQ. QO...... Maximum No. BurialSpaces... .?........... B1k. 42, Un.4
NO.
. 800.00
Net Pa1d S ..................
For interment of Jennie
Stanislaw Jaworowski -
l'~S4
Monument permitted....................... H4e016en Cid10wski
I ...-. -- ) LJ/8 5 Seagrape Dr.
& - lVI, t-OJ I=>, /1- 17 (Ft.Pierce,F1. 34982
(Data above tII11 line lor City Record only)
C!!itu Df &thnstinn
OIfmrtrry
I ffll
.i2S4
NO.
THIS INDENTURE MADE TIaII
12th
day 01
December
89
A. D.. 19......,
between the City 01 Sebutlan, a municipal corporation existing under the laws 01 the State 01 Florida, .1 Grantor and
Helen Cid10wski
. .. . ... ... .... ...... .... ........... 'S1j.06 "S'eagi::ape' 'fir]: ve...................... . .... .......................................
................ ....................f,1;......:p.i.~;r;'~l;!.,. .fJ..Q.t;;i,4~.'. ..~~.9.e.4........ ........... ........ ............ ...... .... ...
Indian River Florida
of the County 0' ............................................. an:l Slate 01 .......................................................
u Grantee, WITNESSETH.
That the Grantor for and in cOnsideration of the sum of S ..... .~~.9 :.9~.......... .to it in hand paid, the receipt whereof is herewith ac-
knowledged, does by this instrument grant, bargam, seU, release, convey and confum unto the Grantee . 11 ~.J; . .. heirs, legal representatives and assigns
the foUowing property si.f,lJa.ted ~ Sebastian, Indian River County, Florida, to-wit:
AU of Lot(s) 9 . . &.~ , Block, . . . ~ 2 .. ,UNIT .4........... ,of Sebastian municipal cemetery as per Plat Number 1 thereof recorded in Plat
Book 2, at page 6S of the pubUc 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, Fiorida.
To Have and to Hold the same forever; provided that said property shaU be used solely and exclusively for the interment of the hu~ 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 fust above written.
CITY OF SEBASTIAN, FLORIDA
At....~I'fI-"d)) f) &f.i!~~.......
U City Clerk
By ...~~..~~..........
Ma,or
Signed, Sealed und Delivered
i1~~....
~/ 'J~'
, . .. ." I t.,
-:. .-::~...{.~~<. ..y. .'...... .... .............
(QIit\{ "eat)
STATE OF Fr.ORIDA
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A.
1. Name of
Deceased
(Type or Print)
First
Jennie
Middle
J.
last
Jaworowski
j, /~
6 /(;2-
1/1
DATE Month Day Year
OF
DEATH December 12, 1989
..
State of FIorlda,Aartment of Health and Rehabilitative Serv.. Vital Statistics
AJIJ[ICATlON FOR BURIAL - TRANSIT PER
2. Place of Death
County
St. Lucie
City, Town or Location
Port St. Lucie
Name of (If neither, give street address)
~~P'WCA Medical Center of Port St. Lucie
3. Name of Medical
Certifier
Darshan Aggarwal, M.D.
4. Name of Funeral Home/
Direct Disposer
Yates Funeral Home,
5. Check a 0
APpro-
priate
Box
Medical Examiner Address
2215 Nebraska AVenue
x Physician Ft. Pierce, Fl 34950
Address Fla. LIe. No.lReg. No. Phone Number (Area Code)
P.O. Box 777
Inc. Ft. Pierce, Fl 34954 219 407-461-7000
The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
Phone Number
464-4044
b 0
was contacted on within 72
hours after death. He/she verified that this death was from natural causes, that there was no accident
nor other external cause of death, and that will complete
and sign the medical certification of cause of death.
c 0
.......,
was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
6. Place of
Final Disposition:
7. Funeral Director /
Direct Dispose"'lilliam J.
medical certification.
In state cemetery/ Sebastian Cemetery
crematory - name/county: Ind ian River
Signatu . No.1 Reg. No.
Farrell,Jr. 2199
Removal
from state Donation
Date Signed
December 12, 1989
B.
Permission is hereby granted to dispose of this body.
o A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted as undue hardship
would result from filing within the normal time limit. If the certificate cannot be filed within this extended time limit, a "Funeral Director/Direct
Disposer Report" will be fil with the local Registrar of the County in which death occurred.
o No extension of time for ill the death ce TlCate re uested.
Registrar or
Subregistrar Signature
Permit No. 219-443-89
Ps~:12/ 12/89
Date Certificate
Due:
C.
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 obtained before disposal by any of the above methods. A waiting period of 48 hours after
death is required for all cremations.
D.
CEMETERY OR CREMATORY
Methods of Disposition:
o BURIAL
o CREMATION
Signature of Sexton )
or Person-In-Charge )
o STORAGE
o OTHER (Specif~
,(.1' J. , ?-r'
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 HRS County Public Health Unit In the County where disposition occurred.
HRS Form 326, Feb 89 (Replaces Oct 87 edition which may be used)
(Stock Number: 5740-000-0326-2)
J.