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Home My WebLink About4-40-03 Paid by cEMETERY Receipt No... ..~........ D.ted. .~~.C!: ~/ ~.q............. .t~k 3 46 400 00 Unit 4 Ust Price S . . . . . . . .. . . . . . . . . . . MaxImum No. Burial Spaces. . . . . . . . . . . . . . . . . NO. Net Paid S . .400.. ao....... Monument permitted... ................... . Albert Gagne interred 12/1/90 Lot 3 (Data aboye Itll. line lor C1tT Reeord only) '1302 Priscilla Potter 616 Ervin St. Sebastian, Fl. 32958 Cltltv Df l',bastlan Cltrmrtrry Urrb NO. '1302 behnrn thr City 01 Srba.tlan, a D1unlefpal eorporatlon al.t.... WIder the law. 01 the State 01 Florid.. a. Grantor and THIS INDENTURE KADB 'I1IIa . ..?9 t:b......... .... day 01 '" .N.o.vemb.er........................... A. D. 119.0.... Priscilla Potter . . . , , . . . . . . " . . ..... .......................... 6 i 6' . 'Ervin" s t'r'ee t................. . . .. .......... ............................. ...... ........ .... ........................... Seb.as.tian.~. .F.I.orida..329.5B. ......... .............. ..................... of the County 01 ...... ))~<;l.t ~m ..lU.. Yo ex.. . .. . .. . .. . .. . ... an'l Slate 01 ...... Fl.o r ida.. .. .. .. .. .. .. .. .. . .. .. .. .. . .. .. .. .. . u Grantee, WITNESSETH. th S 400.00 h d Id That the Grantor for and in consideration of e sum of . . . . . . . . . . . . . . . . . . . . . . . . . . to it In an pa ,the receipt whereof is herewith ac- knowledged, does by this Instrument grant, barpln, seU, release. e:onvey and confirm unto the Grantee . h~.J; . .. heirs, tepl representatives and .ssIgn. the foUowfng property situated In Sebastian. Indian River County. florid.. to-wit: AU of Lot(s) . ~.~~. . Blode, . ;.Q.... . UNIT. At.......... . of Sebastian munfdpai cemetery as per Plat Number 1 thereof recorded In Plat Book 2. at page 65 of the pubUc records In theomce of the Clerk of the Circuit Court of SL Lude County of florid.; IIId land now lyina and befn8 in Indian River County. Florida. To Have and to Hold the lime forever; provided that laid property shaU be used IOlely and exclusively for the Interment of the human dead and shan be used. kept and maintained at aD times in accordance with the rules and regulations. ordinance. and relOlutlons of the City of Sebastian, Florida, hereto- fore. now and hereafter adopted or provided for the aovernment and operation of said cemetery. The conditions. restriction. and requirements contained in this instrument shan be covenants runnJna 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 iueb rules. rqulations, relOlutlons and ,ordinances and the conditions of the dt!ed of conveyance thereof then the title of such owner in and to said property shaU terminate and the' lime shall revert to the City of Sebastian, Florida. IN WITNESS WHEREOF. The said party of the first put has Clused thfslnstrument to be executed In fts name and on ft. behalf by Its Mayor and attested by Its Cfty Clerk and its corporate seal to be hereto afflxed. the day and year first above written. Att~~~..fb...{)l/~~....:..... f City aerk CITY OF SEBASTIAN. FLORIDA D, .~.~~.. SI,nl"d, Srllled and Delivered !1~h/,:r~nCll!O~'/. , U Z~ /0. . l~:x:~::::::.::.. (Glitv jltaJ) STATE OF FJ.ORJDA COl'NTY OF INDIAN RIVER I HRIlEDY CERTIFY. That 011 thla .......~9.t.Q..........day of .........No.v.ember............................. 11.90. bl'fore me personally appeared.... W.... .~.... .c;.Qny.~:r.~................................ and .. .Ka.thr.yn..O! Halloran.... respc'ctlvr.ly Mayor and City nnk 01 the City 01 Sebastian. . munlell.al oorporatlon under the law. 01 the State of Florida to me known 10 be the Individual. And officers delC:rlbed In and who aeeut~ the lorl'lOln, eotIveyanee to Priscilla Potter ....................................................................................................................................... . . . .. . .. . . . . .. .. .. . . . .. .. .. .. . .. .. . .. .. . .. .. . . . .. .. . .... and lenrally aeknowled,ed the elU!tuUon thereof to he their free aet and deed IS sllcl. officers thereunto duly authorlaed r and that the Orllclal .eal 01 ..Id corporation I. dulf .tlllled. thereto, and the said eonyeyanee Is the lief .nd de~ 01 Hid eorporatlon. . . WITNESS my .I,nature and orlidal leal at leba.tlan, In the County 01 Indlait ~fver and State of Plorld.. the day .nd year IlIIt dore..ld. . ..~~;;~..~.............~.... My COIIUIlI..,on expire.. rb~'IrJ r:.:~::~, Srtb cf F:C!:lda II, (:r.m:!r::::1 E::;:!re, !:d !O, 1994 Name , A I bey+ (.." .Q. ~ fjcf ......, Unit y c..Jo Block Lot ..3 Date of Mark-out 11- ;). '1- 90 Name of Funeral Home /)." r""70" ,jf (<. u i'1i 1< Time I : ()O pH. I Date of Burial \a, ,/ / ,/ Authori~ed by ~4L"d"/}fj.~,<:--? ",;7'''" _.~,/ C/' r ~ . n.__~ ~ --------':-'\.--..---. " DEED 111302 ~~ER~ PRISCILLA 616 Ervin S~eet Sebastian, ~f. 32958 Lots 3, 4 Block 40 Unit 4 Albert Gagne interred 12/1/90 tiltV~a~ne~~ cllf1 wi Lot 3 \ -- '- - Paid by CEMETERY Receipt No... ..~~.~........ Dated. .~~l ?-.?/~.9.............. ~~~~k 346 . . 400.00 Uni t 4 ListPnce $.................. Maximum No. Burial Spaces . . . . . . . . . . . . . . . . . Net Paid $ . .400... 0.0....... Albert Gagne interred 12/1/90 Lot 3 (Data above tbt. line tor elt)' Record only) NO. Monument permitted. . . . . . . . . . . . . . . . . . . . . . . 1302 Priscilla Potter 616 Ervin St. Sebastian, Fl. 32958 .. . .. &if>1 THE SEBASTIAN CEHETERY City of Sebastian Sebast1an, Florida FROH: RECEIPT IS HEREBY ACICNONLEDGED OF THE SUH OF: h-aJ~ /~L/ j7~ ~/tf, ~~. ~~L..A~Aj, ~.L. 302 'SF , Dollars ($ 7"dd. ~ ) on this .:2?1;lG day off~~' 199tJfor the purchase of the following described Cemetery Lot( J upon the terms and condit1ons as stated herein: Description of Property: Cemetery Lot(s)' 3'" .~ Block' '70 Purchase Price: ~~ ~~ Unit' ~ Dollars($ 'Yt:hI. Q-c;) ) Terms and'conditions of sale: This contract shall be binding upon both parties, the seller and the purchaser, when approved by the owner of the property above described. I, or we, agree to purchase the above described property on the terms and conditions stated in the foregoing instrument: The City of Sebastian agrees to sell the above mentioned property to the above named purchaser(s) on the terms and conditions stated in the above instrument. ~baS~~ Witness "" . . POST OFFICE BOX 780127 0 SEBASTIAN, FLORIDA 32978 TELEPHONE (407) 589-5330 0 FAX (407) 589-5570 December 3, 1990 Ms. Priscilla Potter 616 Ervin street Sebastian, Florida 32958 Dear Ms. Potter: Enclosed is Cemetery Deed No. 1302 for Cemetery Lots 3 and 4, Block 40, Unit 4. If you wish to have this deed recorded you may do so at the office of the Clerk of the Circuit Court, 2145 14th Avenue, Vero Beach, Florida. Also enclosed is a form - Return for Transfers of Interest in Florida Real Property - which must be filled out by you and completed by the office of the Clerk of the Circuit Court when and if you have the deed recorded. We are enclosing two copies of Receipt No. 648 and ask that you sign and return to us the copy marked with an "X" and retain the other copy for your records. A stamped, self-addressed envelope is provided for your convenience. Very truly yours, ~fh D;;;~ Kathryn M. O'Halloran City Clerk KMO:js enclosure ....iLl .. . ~ - .. o IF' ~ o o D"' D"' ... o - .. ~ .,.C FJ_ mil!! ~i!z :!f;lm ~~=. ;n~... Iii film ... ~ 4 ~ en w "'C;-~--:S'7':'C':""'. - :7':'~-~{'-,'-;:. <. ':"": I(p.~l State of Florlda,.rtment of Health and Rehabilitative servi.ital Statistics APPLICATION FOR BURIAL - mANSIT PERMIT f-~ -oj A. 1. Name of Deceased (Type or Print) First Albert Middle Anthony Last Gagne DATE OF DEATH Month Day 11/28/90 Year 2. Place of Death County City, Town or Location Name of (If neither, give street address) Hosp. or Inst. 3. Name of Medical Certifier Alan Collin, M.D. 4. Name of Funeral Home/ Direct Disposer Medical Examiner Cen er Address Phone Number Physician 1801 S.E. Hillmoore" Drive,Pt. St. Lucie, Fl 34952 Address Fla. Lie. No./Reg. No. Phone Number (Area Code) 5. Check Appro- priate Box a 0 The medical certification has been completed and signed. A completed certificate of death accompanies this application. b ~ June was contacted on 11/29/90 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 Dr. Collin 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 medical certification. 6. Place of Sebastian Cemetery Final Disposition: 7. F4[1eralDirector / Dir4/"'t ni"pOfl9r>- Indian River F.E. No.me~. 14cr 72 Removal from state Donation Date Signed 11 28 90 B. BURIAL - TRANSIT PERMIT Permit No. 1228-90-0581 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 filed with the Local Registrar of the County in which death occurred. o No extension of time for filing the death certificate request d. h 4 Registrar or Date , .., t;', Date Certificate Subregistrar Signature Issued: II. ""1 Due: C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL-AT-SEA Signature or Medical Examiner, , Medical Examiner Date , 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: Xi BURIAL o CREMATION Signature of Sexton ) or Person-in-Charge ) o STORAGE o OTHER (Specify) /~ 'j .i~c;x . Place of Disposition Date of Disposition Sebastian Cemetery December 1, 1qqO 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. W HRS Form 326. Feb 89 (Replaces Oct 87 edition which may be used) (Slock Number: 5740-000-0326-21