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Paid by CEMETERY Receipt No... ..;
UIlf'rice S.... ~.9~: .q9.....
800.00
Net Paid S ..................
......Dated.1Rt.~?/?f................. Lots 51 32
Block'J/
Maximum No. Burial Spaces................. Uni t 4
NO.
Monument permitted. . . .. .. . .. . .. . .. .. .. . . .
lJ82
(Data abon thla line for Clt, R<<oftJ only)
<!lUll nf &,hastiatt
atrmftrry 'rrb
"1382
NO.
THIS INDENTURE MADE nta
19th
d.., of
October
92
A. D.. I.......,
het,,'..n 'he City 0' S.butl.n, a lDunlelpal corporation ealatlnl under the I.... of the State 0' Florlc1.. .a Grantor and
,.,.".,......... ...... ............. ......n9.ndd. .D....&..J.eanne..M....Ca~aV,6nt,.............. .................. ......
731 Dempsey Avenue
",................... ..... ....... ...... ..Sebastia.n., ..F.1ot:ida..329.58..... .....,.............................. ........
Indian River Florida
0' the County of ,............................................ .n'] Slate 0' ....................................,..................
u Grantee. WITNBSSETH.
TNt the Grantor for and In consideration of the sum of S . .~R9.'. 9.9. .. .... . . .. . ...10 It In hand paid, the lecelpt whereof I. herewith ao-
kno..ledpd, doe. by this Instrument pant, barplia, ..0. releaae, conyey and confirm unto the Grantee . ~.~~.;;r; heirs, Jepl lepre_tatly. and aul[ll1s
the foDowllll property a1tuated In Sebaatlan, Indian RIver Co~nty, Florid.. to-wlt:
31&SiI 37 4
AD of Loth) ..... . .. , Block. . . . . . . .. ,UNIT ............. ,of Sebastian munldpal cemetery as per Plat Number I theleOf recorded In Pia",
Book 2, at pap 65 of the public lecord.ln the office of the Clerk of the Circuit Court of St. Lude County of Florida: said land now Iytna and being
In Indian RI_ County, FloridL
To Have and to Hold the ame roreYtlr: proYided that aid property shan be uaed IDIeIy and exclusiYely for the interment of the human dead and shall
be UIIlIl, kept and maintained at aD IIrne.1n accordance with the rules and replatlons, ordinance. and lelDlutlon. of the City of Sebastian, Florida, heleto-
fore, no.. and hereafter adopted or proYlded for the lIOftmment and operation of aid cemetery. The condition., restriction. and requirements contained
In this instrument s"O be co_ts runnin. with the land. In the event of the faUure of the owner of any property situated within aid cemetery to ob-
..m and comply with inch rulea, rqulallons, lelDtutlon.and ,ordinance. and the condition. of the dl!ed of conveyance theleOf then the title of ~ch owner
in and to aid property IhaU terminate and the ame .haIl re.ert to the CIty of Seballlan, FlorklL
IN WITNESS WHEREOF, The aid party of the lint part "'. couaed this Instrument to be executed In its name and on It. behalf by It. Mayor and
attested by III City Clerk and It. corporate _I to be hereto affixed, the day and year lint above written.
CITY OF SEBASTIAN, FLORIDA
Clt, Clerk
B, .,.,.....,.......... .. . .. .. .. .. .. . .. .. .. . .. .. .. . .
M.yor
Att..lI
111.....1. Se.led and Dellnred
In the Preaenee olr
(GJitv 'eal)
STATE OF F..DRIDA
COl'NTY OF INDIAN RIVER 19th 92
October
I HEREBY CERTIFY, That 011 thla ..............,........,d.' n' .......,',..,......................................, I..,..,
h,'ore me pe.......lly appeared .~~~.~.~~..~.~..?'?~~~~.............................. and ..~~~~~J~..~:..~.'.~.~g'?~.~~
rea"""lIvrly M.yor and City C1rrk of the City 0' Seba.lI.n, a munld,1I1 eorporaUon under the law. 0' the State of Florida tn me known
10 he the Individual. and oW.,.... desrrlbed In and who exeeut.", the 'on-lJOlnl ....veyanee to
....,....................................... ..P.Qm'\l.rl.. n .... .~.. ;J:~~"n~ ..!:t.. ..C.~.I;l,6Y.'ant.............. ......................
. . . . . . .. . . . . . . . . . .. .. . .. . .. . . .. . .. . .. .. . .. .. .. . .. .. . .. .. and &eyerally ..,knowled,", the eaeeullon thereof to be their 'ree ad and deed
II sllch o"Iee.. lhereunto dul, luthorlsed I and that the Otnclal ...al of 1.ld corporation la duly afnxed thereto, anll the IIld eunvrfance
I. thc aet .nd deed 0' aald corporation.
WITNESS my .lllla...re and oftlelal _I at Sebaatlan, In the County of Indian Rlyer and State of Florida, the da, and ,ea.
last afo.....ld.
Notary Publle, State of Florida at Lor...
My eormalaalon eaplrell
Linda M. Lohsl
Name
Li
D. :,
-,; "
..'
t".
Unit
Block
-;,
Lot
Date of Mark-out
,/I//7/'j'7
~ -
Date of Burial
1111'1"' /17
, f
Time
fi:O()
i~; '~"'O ,..;
Name of Funerall-fome-"> -'cirri i( ::;
X:L=
- ." .-
, '
~,.
.'. '';;'/7-'
.." . ,","'_" ._..fr, .
I
Authorized by
,J:
'-"-';:,l~~,~::t'E",:~1t;-;~~,:, ':
I~
State of Florida, Department of Health, Vital Statistics
APPLlC. FOR BURIAL - TRANSIT PERMIT
.
h 3/, 3c?-
b 37
!I 1
A.
1. Name of
Deceased
(Type or Print)
First
Middle
Last
DATE
OF
DEATH
Month
Day
Year
2. Place of Death
County
Indian River
3. Name of Medical
Certifier
Seth Baker, D:.O.
4. Name of Funeral Home/
Direct Disposer
Strunk
5. Check
Appro-
priate
Box
Donald
City, Town or Location
D.
Casavant 11
Name of (If neither, give street address)
Hosp.or
lnst. Sebastian River Medical
Address
15
97
Roseland
~ Medical Examiner
Center
Phone Number
Xl Physician 8005 83rd Avenue, Sebastian, FI 561-388-4606
Address Fla. Lie. No.lReg. No. Phone Number (Area Code)
1623 N. Central Avenue
Funeral Home Sebastian, FI 1228 561-589-1000
a 0 The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
b 0
Donna was contacted on 11/17/97 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. Baker 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. Funeral Director/
Direct Disposer
I ndian River
F.E. No.1 Reg. No.
1862
Removal
from state Donation
Date Signed
11-16-97
B.
BURIAL - TRANSIT PERMIT
Permit No. 1228-97-0466
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 fiied with the Local Registrar of the County in which death occurred.
IX No extension of time for .. the death certificate requested.
AC!:l;~lrC:l1 UI
Subregistrar Signature
Date
Issued:
"/I:S/'7
Date Cert1.cate J a .
Due: 11.rJ1 /-,7
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.
Methods of Disposition:
m BURIAL
D CREMATION
D STORAGE
o OTHER (Specify)
CEMETERY OR CREMATORY
Place of Disposition J ~ L '" -t;,..", a .A"Y1..R-J 0 ~ }
Date of Disposition !/Qu~ 1'1, I ~ ~7
Signature of Sexton )
or Pers6n-in-Charge ) r';'" ~ c.~
This permit must be endorsed by the Secton 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.
DH 326, 10/96 (Replacea HRS Form 326 which may be used)
(Slock Number: 5740-000.0326.2)
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