HomeMy WebLinkAbout4-41-34,
1��ts33, 34
�/� �ck 41
� Paid by CEMETERY Recoipt No. . . . . . : � 4. . . . . . . Dated . . 1 O I 8 I 9 O . . . . . . . . . . . . . . NO.
' �Jnit 4
List Pricxi S . 4 Q Q : Q Q . . . . . . . Maximum No. Buriai Spacea . . . . . . . . . . . . . . . . . � 12 9 7
Net Paid s . 400 ; 00 , , , , , , . Monument permitted . . . .. . . . . . . . . . . . . . . . . . . C onni e C i e s 1 ak
Edward B. Cieslak interred 10/6/90 Lot 34 c/o Darlene Kennedy
480 Toledo St.
(Dat� ebove thts line for Gty Itecoed on1Y) S e b a s t i an , F'' 1. 3 2 9 5 8
�i#� �f �P�tttBftMri
�Pl1t��P�' �Pp� No. '1297
�
TH18 INDENTURE MADE 17ds ....�C.11 ............. dsy ot ....00kP.b.4X............................. A. DM 19.90..
betHeen the Clty ot Sebastian. a municlpel corporstlon e:leting undcr the laws ot the 3tate ot Floride, es Granto� and
Mrs. Connie Cieslak
.......................................................................................................................................
c/o Darlene Kennedy
...........................................48Q..To�.ado..St......................... .. ........................................
ot the Connty oi .Indi.an..River Sebastian, F:n� 58958 Florida ................................. ...
ta Crantee, WITNESBETHt
That the Grantor for and in consideration of the aum of S 4 � �• � � ,,,,,,,,,,,, to it in hand paid, the moeipt whereof ia hemwith ao-
..............
knowledged, does by thia instrument grant, bargain, sell, releax, convey and confirm unto the Grantee ,, h e r. , heira, legal reprexntativea and asaigns
the following property aituated in Sebastian, Indian River County, Florida, to-wit:
All of Lot(s) . 3�.�.3�}Block, , 4,�„ ,,,, UNIT .,�+. ....,..,., of Sebastlan munidpal aemetery aa per Plat Number 1 thereof noorded in Plat
Book 2, st page 65 of the public rawrda in the offlae of tha C�erk of the Circuit Court of St Lude County of Florida; said Iand now lying and being
in Indisn River County, Florida.
To Have and to Hold the same forever; provided that aaid property sha(I be uaed sokiy and exclusively for the interment of the human dead and shall
be used, kapt and maintained at all timea in accotdance with the rulea and regulations, ordinances and resolutiona of the City of Sebastian, Florida, hereto-
fore, now and hereafier adopted or provided for the government and operation of said cemetary. The conditiona, reatrictions and requirements contained
in thia instrument shall be covenants running with the land. In the event of the failure of the oamer of any property situated within seid ametery to ob-
serve and comply with such rules, regulations, resoluHons and ordlnanas and the conditiona of the de'ed of conveyanca thareof then the title of such owner
in and to said property shall terminate and the same shall revert to tha City of Sebastian, Florida.
IN WITNESS WHEREOF, The said party of tt�e firat part has caused this instrument to be executed in its name and on ita behalf by its Mayot and
attested by ita City Clerk and its corporate seal to be herato afflxed, the day and yeaz first above written.
Attest: �.�. . � : /. ��_
��_�
� City Clerk
SigmKl, 9esled und Delivered
In the nce o : ��r••••••
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�T A TL� nv� �r nn Tn e
CITY OF SE13A8TIAN, FLOBIDA
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Ma�or
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Name
Unit_
Block
Lot _
Date of Mark-out � � `�
Date of Burial �/ �` / �� Time
Name of Funeral Home
Authorized by
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� State of Florida,�rtment of Health and Rehabilitative Servi�ital Statistics
APPLICATION FOR BURIAL — TRANSIT PERMIT
� �y
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A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
EDWARD BERNARD CIESLAK, SR. DEATH 10/4/90
2. Place of Death City, Town or Location Name of (It neither, give street address)
County Hosp. or
INDIAN RIVER . ROSELAND Inst. ���,JA HOSPITAL—SEBASTIAN
3. Name of Medical
Certifier
NASIR RIZWI, M.D.
4. Name of Funeral Home/
_ __
Direct Disposer
STRUNK FUNER,AL HOME,
5. Check
Appro-
priate
Box
6• Place of 51
Final Disposition:
�• Funeral Director/
B.
a
Medical Examiner
13855 US4� 1
Address
Number
SEBASTIAN, FLORIDA 32958 589-6844
Address Fia. Lic. No./Reg. No. Phone Number {Area Code)
1623 N. CENTRAL AVE.
SEBASTIAN SEBASTIAN, FLORIDA 32958 411228 407-589-1000
The medical certification has been completed and signed. A completed certif"icate of death accompanies
this app►ication.
b� EDIE was contacted on 10/4/90 W�thin 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 DR. RIZWI will complete
and sign the medical certification of cause of death.
c ❑
CEMETERY
was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
medical certification.
In state cemetery/ 1 lAN K1VEK COUNTY
crematory - na /c " y: SEBASTIAN, FLORIDA
S' ature F.E. No./Reg..Dle-_
�,.,,? -�---�--LZ._ 4� 1762
BURIAL — TRANSIT PERMIT
Removal
from state n Donation
Date Signed
10/5/90
Permission is hereby granted to dispose of this body. Permit No. 1228-90-497
❑ A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted as undue hardship
wouki 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 filed with the Local Registrar of the County in which death occurred.
❑ No extension of time for filin e death certificate requested.
Registrar or ' Date 10/5/90 Date Certificate
Subregistrar Signature Issued: Due:
�� 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 disposaf by any of the above methods. A waiting period of 48 hours after
death is required for all cremations.
Methods of Disposition:
C� BURIAL
❑ CREMATION
Signature of Sexton )
or Person-in-Charge )
❑ STORAGE
❑ OTHER (Specify)
CEMETERY OR CREMATORY
0
Place of Disposition SEBASTIAN CEMETERY
Date of Disposition OCTOBER 6, 1990
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 editan which may be used) �
(Stock Number: 5740-000-0326-2)