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Home My WebLink About4-40-04 ts 3 4 Paid by CEMETERY Receipt No.... .~:.......... Dated. .~~.t!-.~/ ~.q.............. .Block 40 400 00 Unit 4 Ust Price S . . . . . . . .. . . . . . . . . . . Maxbnum No. Burial Spaces. . . . . . . . . . . . . . . . . Net Paid S . .400.. QO....... Monument permitted... ................... . Albert Gagne interred 12/1/90 Lot 3 NO. '1302 (Data aboye tld. One lor D17 Reeord 001,) Priscilla Potter 616 Ervin St. Sebastian, Fl. 32958 Gtttg of &rhastian <1trmrtrry Irrb NO. \1302 THIS INDENTURE MADE 'I1lIa . ..~91=:J;1. .. .., : . , , ... dAY 01 .. ..N.ovemb.er...... .................. ... A. 0.. 119.0"'f beh\'t!en the City 01 Seba.tlan, a Dlunlclpal corporatIon exllUn. under the law. 01 the State 01 Florid.. a. Grantor and Priscilla Potter ...,',.,..,...,............ ............ ....... '616' 'Ervin" St'r'e~t'" .................................. ........ ............... ."". ........ ... ............................ Seb.astian.,...F.lDrida..329.5B. .,. ........ ... ......... ..................... of the County 01 ,..... ~n<;1.tAn. .RtY:e.t'......... ......... an',l State 01 ..... .F.lDrida...................... ............... u Grantee, WITNESSETH. . That the Grantor for and in consideration of the sum of S !+. 9.Q ... Q ~ . . . . . . . . . . . . . . . . to it in hand paid, the receipt whereof is herewith ac- knowledged, does by this instrument grant, bargafft, seU, release, Cionvey and confirm unto the Grantee . h~.J;' . .. heirs, legal representativea and assigns the foUowing property situated in Sebastian, lneDan River County, Florida, to-wit: AU of Lot(s) . ~.~A. ,Block,. ;.Q. . .. ,UNIT ..9.......... ,of Sebastian municipal 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 theCkcuit Court of Sf. 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 shaU be used solely and exclusiYely for the interment of the human dead and shan be used, kept and maintained at aU 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 shaU be coyenants ruMing with the land. In the event of the faDure of the owner of any property situated within said cemetery to ob- serve and comply with iuch 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 shaU terminate and the same shaD 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 afOxed, the day and year first above written. Att~~~.Jh,{).t/~~...:..... f City Clerk CITY OF SEBASTIAN, FLORIDA 8, .d/"E..q,~~...:.";;.. Rlgn...d, Sellied Bnd Delivered X~nae~L~/ /J l~~.:tt.'J~~~......~... q~tl)...".~........... (Grit" ~'m) STATE OF FI.ORIDA Name Unit Block Lot ~. ~<~ --- '- /-1/\ h 1<'...: '.J ! 1 - ,..'"'ZJ 1''''''''':; ( "1 , ..:... . '-1' h '--[ .</ 1'\((:) ,'l _./.~>/ /97 ~, /3,197 Date of Mark-out Date of Burial Name of Funeral Hom,a-- 5~',L.f 1"'/ )( t .,/ i .i< /". ,..:f //' Authorized ~~',~'~;~;~;~~';f::::.:.d..</ '~:;~1 .~_. -_:"~A"'___,__,______,_,_,__ "ViS Time :z I c,)() /J .' r ,. -----.-"..-....-.."'--.---..-.. ~~ ,:'1"., . :'~~:-;'.~,~",,":,,"':)7:C"~'B:'1?"""'01i;m-;,"': [lP.~] State of Florida, DepartAt of Health and Rehabilitative Services, Vitetistics APPLlC~N FOR BURIAL - TRANSIT PERMIT 1-10 -CJY A. 1. Name of Deceased (Type or Print) First Middle Last Month Day Year 2. Place of Death County Mary City, Town or Location Louise DATE OF Gagne DEATH May 30, 1997 Name of (If neither, give street address) Hosp.or Inst. I ndian River Memorial Hospital Address Phone Number I ndian River 3. Name of Medical Certifier Noor Merchant, M.D. 4. Name of Funeral Home/ Direct Disposer Strunk Vero Beach ....J Medical Examiner 5. Check Appro- priate Box Funeral a 0 -, Physician 7744 Bay Address 1623 North Central Ave. Home Sebastian, Florida 32958 1228 561-589-1000 The medical certification has been completed and signed. A completed certificate of death accompanies this application. Street Center, Sebastian, FI 561-589-0879 Fla. Lic. No.lReg. No. Phone Number (Area Code) b ;! Julia was contacted on 6/2/97 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. Merchant 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 Final Disposition: 7. Funeral Director/ r"}j{QI"t ni~~Q9er- Indian River F.E. No.1 Reg. No. 1862 Removal from state B. BURIAL - TRANSIT PERMIT Permit No. 1228-97-0260 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 requested. RQ:ilirtr~r Qr, Subregistrar Signature Date .5-' 3- \ l!'!!l....-, Date CertificC:Wq Issued:~ Due: w 7 C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL -AT-SEA , Medical Examiner Date Signature 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: IB=aURIAL o CREMATION o STORAGE o OTHER (Specify) Place of Disposition Date of Disposition ~5.t;~MJ ~_a-;h 9<-. 3) 1171 t Signature of Sexton) or Person-in-Charge ) j.l'U:- .1.~ 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. Q HRS Form 326. Feb 89 (Replaces Oct 87 edition which may be used) (Stock Number: 5740-000-0326-2)