HomeMy WebLinkAbout4-42-29Certificate No. 2247
CITYOFSEBASTIAN
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Barbara G. Mahoney
& /or Sylvia J. Colvin
P. O. Box 780214
Sebastian, FL 32978
In and for consideration of the sum of $1,000.00 is entitled to full interment
rights in the Sebastian Municipal Cemetery for the following lot:
Unit 4, Block 42, Lot 29
of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and
regulations prescribed therefore by the City of Sebastian.
CONVEYED THIS 8th day of March, 2010.
CITY OF SEBASTIAN, FLORIDA
'Al Minner
City Manager
ATTEST:
Sally ,< Maio, MMC
City Clerk
Block
Date of Mark -out Cl 17/ /1 / \
Date of Burial Lb /�� Time
Name of Funeral Home
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LILLIE VERNELL ROLLINGER
July 10, 1926 —June 11, 2011
Mrs. Lillie Vernell Rollinger, 84, died June 11, 2011 at VNA Hospice
House, Vero Beach.
She was born in Holmes County, Florida and lived in Sebastian for 50
years coming from Webster, FL.
She attended Good Shepherd Church of God, Winter Beach.
Survivors include two daughters, Sylvia Colvin and her husband,
Danny of Palm Bay and Gale Mahoney and her husband, John of
Sebastian; sister, Winell Franklin of Leesburg; granddaughters, Angela
Keen of Winter Haven, Tina Vickers of Palm Bay, Lori Smith of Vero
Beach, Lisa Brennan of Smithfield, VA and Debra Fouch of Stafford,
VA; 16 great - grandchildren and 2 great - great - Grandchildren.
HEANiOF _ State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
ITVPEI
t. Name of First
Middle
Last
Date
Month Day Year
Deceased
Rollinger
of
Lillie
Vernell RWKQWXXX
Death
06/11/2011
2. Place of Death City, Town or Location
Name of (If neither, give street address)
Counb
Haiti or
Indian River Vero Beach
mse VNA Hospice House
3. Name of Medical
Address
Phone Number
cartrer Richard T. Penly
1265
I
36th Street
Medical Examiner
Physician
Vero
Beach, Florida 32960
772/567 -6340
4. Name of Funeral Home /Direct Disposal
Address
Fla. Lic. No No,
Phone No. (Area Code)
Establishment Strunk Funeral
1623 N. Central Avenue
Homes 6 Crematory
Sebastian,
FI 32958
F041870
772/589 -1000
5. Check a- ❑ The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. gR Sharon was contacted on June 13 2011
He /she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Richard T. Pertly, M.D. will complete and sign the medical
certification of cause of death within 72 hours.
c. F-1 was contacted on He /she verified that
, Medical Examiner, will complete and sign the
medical certification of cause of death within 72 hours.
6. Funeral Director! \ _ ,� $jpn ure 11� -. F.E. Reg. No. Date Signed
F04444048 06!113/2 /2011
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228 -11 -0281
F] 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
]2 hours.
R)VD extension of time for film 9 in death certificate has been requested.
1iLl1FJVM or ,J, , -- Date Date Certificate
Subregistrar Signature 1R'Ir1`�Iw\ Issued 06/11/2011 Due; 06/1512011
c. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA
Approval Number: Data
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 CREMATOR)�3e,,S ,\,_, n. ate._,
Method of Disposition: Place of Disposition y,,�('�� (�yY�( -I�-7 lA
BURIAL STORAGE Date of Disposition1L�W�.�J� to 'i(p ITo
CREMATION OTHER (Specify)
Signature of Sexton ) /�
or Person -in - Charge J /� q. �� �r -
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.
circulation Whee: Cemetedar Crematory
veuovr Funeral Dinner or plaid okPOaar
(stock Number 5740 000 reps 2) Pink. LaWI IF,xl er
Sep 26 2008 2:45PM HP LRSERJET 3200
FUNERAL OIRECTQR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
Po n arcriw.o
::formalior con:acr
Kip Kely ^0 - Cemwu.') S,,"", Sex 3511a1) k4Lnx,PV Camelery
(777J 599 -2545
FJNERAL HOME STRUNK
ADCRESS
P-1QNE k'
Crly Clerk's c4ce
Y HaA, 1225 Mar, $(reel
$ebdsfan, F4 32958
'772) 388 -6215 or Jaa 6214
Fpr: (772,' 589.5570
IRAL NOME & CREMATORY
(C�ca Coe) p
OPEN BURIAL LOT Lot 2_9 Block LIZ Unit
—_OPEN CREMAINS LOT BIOCk
— _.OPEN COL'JMBARIUM NICHE Nychee,�''''M�_''''����O,,,ttO''''ck Un�17I
BUR;AL DATE AND SERVICE 71ME•_I I I IOI `& _(W
CRDECEASED L.IIItL VQ�ry211 1�DIl(r� Q�—�
i�'ane
NAME AND SIGNATURE OF LOT OVV DER OR REPRESENTATIVE:
(Moss provide proper docurir r, of wnershlm
Lpignao�re Date
au«ify ;;at I have delen1110ed the c,vne� ship of the above described site Ihal all $ile fees and
aoministralive fees have been paid and 4ulhoree opening of same
NAMF AND SIGNATJRE OF LICENSE ERAL DIRECTOR.
LA Ili (k_1 �M1CCwYM I le t4
name 7AlI �ignawre
_..... _.... ................... ------ Date
Cemalery Sexton Cenlfl ca GOn: � ��-��- -- " "' " " "- "-. ""' --
I ce« Ify that I have Checked (he oviners�ip Inf041'ahOn by viewing the owner's deed and COnllrming
with /C Clerk, oL9ce and shat all fees have been paid
..emy dry S�.lort � Date
This form 10 be provided to Clerk's Off 4 by Sexton for pe'manert record upon cornpielion.
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CERTIFICATE # _1269_ Date conveyed: April 5, 1990_
Lots 28 & 29, Block 42, Unit 4 Refund amount: _$800.00
Original Purchaser: _Mrs. Madlynne Pastor
Court ed Personal Representative: Address: 7545 Agawam Road
- - -! - -------------------------- - - - - -- Micco, FL 32976
%(v$1TY OF SEBASTIAN
Surrender of .Burial Rights
THE UNDERSIGNED holder of burial rights in the City Cemetery for the, following
plot:
Lots 28 & 29; Block 42, Unit 4 of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
having misplaced the original certificate granting said rights but desiring to sell back to the City
all of the burial rights in exchange for a refund of the original payment amount, $800.00 do
hereby surrender all such burial rights with full acknowledgement.of the cancellation of the
original certificate /deed to said lots.
IN WITNESS WHEREOF, the said first party has signed and sealed these presents
the day and year set forth above.,
Hannah Pastor — Daughter of Madlynne Pastor
Proof Attached
STATE OF FLORIDA
COUNTY OF r
The foregoing instrument was acknowledged before me this . I "ay tl 2007 by
Hannah Pastor, daughter of Madlynne Pastor who has produced a deAl 1, C a le. as
identification.
Signature of Notary Public
State of Zlorida
Se '�r�Y�.M,
Ms- Cemetery\Su=der of burial rights.doc =• �a FIp�(�
Co Ndabn Expku Dec 7.200
ComnWM 0 DD 497591...
nded By Nal" NotM Men.
4
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Paby CEMETERY Receipt No... �? :........... Dated .... ./ 5 ./ 9 0 . . ............. .
List Price $ .... NQ: 2 0.. , . , Maximum No. Burial Spaces .................
Net Paid $ .... $ P Q • P Monument permitted ......................
..............
(Data above this line for City Record only)
Lots 28 & 29
Block 42 No.
Unit 4 1269
Mrs. Madlynne Pastor
7545 Agawam Road
Micco, F1. 32976
Titg of orhasfittn
AT
w, r ut r l r r NO. G 9
THIS INDENTURE MADE Md. ..... 5th ........... day of ...April
........................... A. D., 19.9 0..,
between the City of Sebastian, a municipal corporation existing under the laws of the State of Florida, as Grantor and
................. Mrs. Madlynne Pastor
7545 Agawam .Road
. ................. .........................Micco, Florida 32976...... ...............................
..............
of the County of Brt?Vara........................ an-1 State of .. Florida
as Grantee, WITNESSETHs
That the Grantor for and in consideration of the sum of $ . 8 �: , 0 , , , , , , , , to it in hand p
ac-
knowledged, does by this instrument rant ba Paid, the receipt whereof is herewith
B rgain, sell, release, convey and confi m unto the Grantee , ,her, heirs, legal representatives and assigns
the following property situated in Sebastian, Indian River County, Florida, to -wit:
All of Lot(s) 2 A4t,X', Mock, .. 4.Z. , , , UNIT ... 4. , , o , , 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 dried 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 just 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.
Attes 01��
City Clerk
Signed, Scaled and Delivered
;in ithere7sence ofs
............. .
...... .....1. �, .....................
STATE OF FLORIDA
COUNTY OF INDIAN RIVER
CITY OF SEBASTIAN, FLORIDA
By .....`� ..
Mayor
(QIi #g a$rxl)