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Home My WebLink About4-41-22Name �ye,4 /d #1 41 SLtt%L�- 'yX -3 Unit Block Lot Date of Mark -out to - Date of Burial // /A/ // 6 • Time Name of Funeral Home > lie Cp Authorized by /a(v✓LC t�. 11/16/2016 18:56 DIRECTOR'S REQUEST TO . OPENING IN SEBASTIAN I For information contac Kip Kelso . Cemetery Se Sebastian Municipal Cer, (772) 589-2845 City Clerk's Office City Hall, 1225 Main SI Sebastian, F1 3295 Office (772) 38&8215 or 3 Fax. (772) 589.5571 FUNERAL HOME: Strunk Funeral Home and Crematory ADDRESS: 1623 NortCentral Avenue Sebastian, Florida 329. PHONE#: 772-589-1000 (Check One) xxxx OPEN BURIAL OT Lot 22_f OPEN CREMAII4S LOT L OPEN COLUM4ARIUM NICHE N BURIAL DATE AND FOR DECEASED: _ NAME AND SIGNAT (Must provide proper 1ICE TIME: Monday,November 21, RIA ANN LUSARDI SLATER 1e OF LOT OWNER OR REPRESENTATI mentation of ownership) 46185 P.001/001 OF SEBASTIAN CIPAL C MPTERY V '1'4 BASTIAN 10:00 a L St. Sebastian CC service Name Signature I certify that I have dete ined the ownership of the above describ site that all s fees have been paid an authorize opening of same. NAME AND SIGNATU E OF LICENSED FUNERAL DIRECTOR: D. Evans Gam' 0. Signature Cemetery Sexton Certff i cation: I certify that I have the ed the ownership information by viewingowner's d office and that all fees have been paid: J//;r h /14, Cemeibry SdXtori Date This form to be provide4 to Clerk's Office by Sexton for permanen Cord upon 11 /16/2016 Date tefees and administrative 11/16/2016 Date d and confirming with Clerk's State of Florida, Department of Health, Bureau of Vital Statistics ---- BURIAL TRANSIT PERMIT HEALTH DATE PRINTED: November 17, 2016 TRACKING NUMBER: 2016177408 1. DECEDENT INFORMATION Name of Deceased Date of Death GLORIA ANN LUSARDI SLATER November 16, 2016 Place of Death - County City, Town or Location Name of facility, or street address If not a facility BREVARD MELBOURNE WAVE CREST HEALTH AND REHAB CENTER Name and Address of Funeral Home/Direct Disposal Establishment Fla. Lic. No./Reg. No. Phone Number STRUNK FUNERAL HOME. SEBASTIAN F041870 F041870 (772) 589-1000 1623 N CENTRAL AVE SEBASTIAN, FLORIDA, 32958 Funeral DirectorlDirect Disposer Fla. Lic. No./Reg. No. GARY D. EVANS F065074 2. BURIAL - TRANSIT PERMIT The Florida Department of Health, Bureau of Vital Statistics hereby grants permission to dispose of this body in accordance with Chapter 382, Florida Statutes. Permit Number: November 16, 2 16 01 Date Issued: November 16, 2016 State Registrar 3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL-AT-SEA, or HOSPITAL DISPOSITION Authorization given by Medical Examiner District Approval Number: 4. CEMETERY OR CREMATORY Place of Disposition: SEBASTIAN CEMETERY M aLi / Method of Disposition: BURIAL Date of Dispositioh: I {O EDRS maintains all statutorily required information regarding the death record and related burial transit permit, therefore, returning the permit to the county health department is no longer required. If the Place of Final Disposition wishes to retain the copy of the permit for their file they may do so. DH 326E, 10/12 64V-1.011, Florida Administrative Code FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY 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 FUNERAL HOME: Strunk Funeral Home and Crematory— SEBASTIAN ADDRESS: 1623 North Central Avenue, Sebastian, Florida, 32958 PHONE#: 772-589-1000 (Check One) xxxx OPEN BURIAL LOT OPEN CREMAINS LOT OPEN COLUMBARIUM NICHE Lot-22—Block 41 Unit 4 Lot—Block—Unit Niche Block Unit N S E 9- - BURIAL DATE AND SERVICE TIME: Monday,November 21, 2016, 10:00 am - St. Sebastian CC service FOR DECEASED: GLORIA ANN LUSARDI SLATER Name NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership) George T. Slater Gechae U. Uateh 11/16/2016 Name 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: Gary D. Evans Name Gary 0. Evans 11/16/2016 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: Cemetery Sexton Date This form to be provided to Clerk's Office by Sexton for permanent record upon completion. CITY OF SEBASTIAN 10395 ADMINISTRATIVE SERVICES RECEIPT Name &4UMn 1 "14-20 i J Cash Date "I "' 1116 Udhheck # '7s -(,c) ❑ Credit Amount Paid 001001 208001 Sales Tax 001001.220000 Security Deposit 001501 362100 Taxable Rent 001501 362150 Non -Taxable Rent 450010 369900 Airport Badge 001001218010 CobraServe 001501 354100 Code Enforcement Fines 001501 347557 Community Center Revenue 001501341920 Copies 001501 351140 Parking Citation 001501 342100 Police Security Services 001501 329200 Site Plan Review 001501 329300 Subdivision/Plat Review 001501 329100 Zoning Fees 0013'0► - 3*3ffa5- 4lsv.�o UA1I r 4 A19-4 Ldr ag, 4 Total Pai L 5�. 0 d Init Is Security Dep Held - Amount $ Check # White - Dept. of Origin • Yellow - Admin. Svcs. • Pink - Applicant Maximum No. Burial Spaces. . . . . . . . . . . . . . . . . Lots 21,22 Block 41 Unit 4 NO. - - Paid by CEMETERY Receipt No. . . . . List Price $ .. ..f~ ?Q .'. 9.Q ..... NetPaid$ ....Q5.Q...9.Q..... J 8/16/90 . . . . . . . . . Dated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Monument permitted. . . . . . . . . . . . . . . . . . . . . . . 1.?~2 Frank Lusardi interred 8/16/90 Lot 21 (Data above this line for CUy Record only) Mrs. Gloria Lusardi 5902 S. River Run Dr. S~pastian, Florida 32958 ~.,~~:~._----..~_..- ~-....~ aritt! nf t9tbu.utiuu OIrmrtrry ilrrb l~~2 NO. THIS INDENTURE MADE TIaII ...~~.~h-............ dRY of ....4~g':1.l?~.............................. A. D.. 19...~9, between the City of Sebastian, a municipal corporation existing under ttie laws of the State of Florida, os Grantor and . . .. . . . .. .. . ... ................... '~+'!?"" . Gl.O;r:;i.~. .L)..l.s.a.:r;.d;i..... ..... . . " ..... .. 5902 S. River Run Dr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . ,S. <;!.O.& Ei t. i.an .,. . .F.! Q r. i.da... 3.2.9 .5. 8. . . , . . . . . . of the County of .. ..J;nc,i.i.cH1 ..R:\.Y~:r..................... an'l State of ...... .:f,J,.9:r.i.q.~.................................... 18 Grantee, WITNESSETH I That the Grantor for and in consideration of the sum of $ . p.5 Q ,.Q O. . . . . . . . . . . . . . . . to it in hand paid, the receipt whereof is herewith ac- knowledged, does by this instrument grant, bargam, seU, release, 'convey and confirm unto the Grantee .. R~ ~ .. heirs, legal representatives and assigns the foUowing property situated in Sebastian, Indian River County, Florida, to-wit: AU of Lot(s) A 1.&~.2, Block, . . ~.~ . .. , UNIT .... A . . . . . .. , of Sebastian municipal cemetery as per Plat Number I thereof recorded in Plat Book 2, at page 6S of the public records in the office of the Clerk of the Circuit Court of S1. 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 mles 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 mles, 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 lust above written. CITY OF SEnABTIAN, FLORIDA Attest: C!:(~?lIr.7~rh .... V.';! tJU!i!(f,-14:~".". () City Clerk B1~~~"... Ma,i' Signl'd, Scaled and Delivered hi the Presenc~ o!: %. '/J~ . f ~~. .. -.~ / h'~':~ ~?!, ((!r:;, ~.f;?. ..;) :~.< ~ ........ ... /~"1 . /, . · rC?,tt~utGL.? :.. ~.," '<-.' ~t~.-L/...",.. . I ~..,. (OIitlZ jieul) STATE OF FLORIDA