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Home My WebLink About4-36-24 -- . Paid by CEMETERY Receipt No.. .~' LI,t Price S . .~! ~:.C!9. .. . . . Net Paid S ..~ ~~:.C!?..... .... .. . . Dated. . . . Y?fJ/?? . .. . . . . . . .. . . . .. lots 2 Block".~ . Maximum No. Burial Space, . . . . . . . . . . . . . . . . Uni t 4 NO. 24 ---- Monument permitted.. . .. . .......... ...... . .1504 (Data above thll line for City Ikcord ooly) (l!Uy nf &rhustiuu <!trmrtrry (115J'1 irrll NO. THIS INDENTURE MADE TIoII 26th day of ........ April 96 A. D., 19....... bet,,'ern Ihe City at SrbBltlao, a municipal corporation exlltlng under the JawI at thr State at Florid.. al Grantor alld Dorcel Thompson '1254(J 'Roseland . Roa:d' .............................................. ............. .P:O.... ~?~. ~.~~~. .~~~~.~~~.~.~.. 3.~957........................................, of the County ot .. )n~~n. R:\.Y:~):,.. . .. ... .. .. .. .. .... ..... anJ St.te of .......... )n.p~;i.Q.a. . .. .. .. .. .... . .. .. .. .. .. .. .. . .. .. . II Grantee, WITNESSETH I T"'t the Grantor for and in consideration of the ,urn of S .~ I ~ : ~ . . . . . . . . . . . . . . . to it in hand paid, the receipt whereof is herewith ac- knowledged, does by this instrument grant, barg..m, sell, release, convey and confirm unto the Grantee . ~~!'l. . .. heirs, legal representatives and a.signs the foDowing property situated in Sebastian, Indian River County, Florida, to-wit: AD of Lot(sf:~. ~ .?~ Block, . . ?q . .. ,UNIT ...~......... ,of Sebastian municipal cemetery a. per Plat Number I thereof recorded in Plat Book 2, at page 6S of the pubUc record. in the office of the Clerk of the CirCllit Court of St. Lucie County of Florida; said Iaod now lying and being in Indian River County. Florida. To lIavc and to Hold the same forever; provided that said property .hall be used solely and exclu.lvely for the interment of the human dead and .haU be used, kept and maintained at all times in accordance with the rules and regulation.. ordinance. and resoiutlon. of the City of Sebastian, Florida, hereto- fore, now and hereafter adopted or provided for the government and operation of said cemetery. The conditions, restriction. and requirement. contained in this in.trument ....11 be covenant. running with the land. In the event of the failure of the owner of any property .Ituated within said cemetery to ob- serve and comply with such rule., regulations, resolutions and ordinances and the condition. of the deed of conveyance thereof then the title of .uch owner in and to said property .haU terminate and the same .hall revert to the City of Seb~.tlan. Florida. IN WITNESS WHEREOF, The .aid party of the first part has caused thl. in.trument to be executed in Its name and on It. behalf by it. Mayor and attested by it. City Clerk and it. corporate "al to be hereto am"ed, the day and year first above written. CITY OF SEnABTIAN, FLORIDA Attrst~'fr .)11. (21!at(1-:{.~... Clly Clerk By ~:.,.>~..~e.;4tA?~",~.I........ C<.~ Mayor ~:'f'O'r... !iignl'd, SCRJerl and Delivered In the Presence of t )!J? ..~(~~.....e.'~0~"',:""", ..... ...... / ... ..; '0d.n.~€..-.-.. .-.Cr4d(.,.d~....... . ...... ~TE OF FT.ORIDA COl'NTY OF INDIAN RIVER ((fiitll ~eal) 26th I HEREBY CERTIFY. nat on thl. ....................... .dH}' 01 April ............................................., 96 I'.. ... b,""re me perlonally appeRred .l.o~~.~..~....~.~r.~~~~h.t....... ... and Ka.thryrU~: ..<?'.~g<?~~~........ r"pl'clivrly Mayor .nd City Clerk ot the City of SebR.UAn, . munlelplIl eorpornUon undrr the I.... of thc Stole 01 Florid. to me known to bt' lh~ Jndh'idllUhl und ()'((errs described in ond who ~xecuh~d the ion.guing CURVI~YRnce to . . . . . . . . . .. .. . .. . .. .. .. .. . . . . . . .. . .. . . .. . .. . . P<;>:r:c;:~l. .ThQ\l!p~Qn .. . . . . . .. . . . .. . . . . . . .. . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . ... . . . . . . .. and severnlly acknowledgrd lhe execullon thereot 10 be their Ire. .el nnd deed !IS such oUicrrs thereunto duly authorlsed; and that the 0((lci81 sell I of said corporation Is duly affixed thereto, ftnll the said cunve-yanCt~ i. the IIct IIml deed of ..Id corporaUon. I..t ",:'~:~~SS my .lgoAlure and ottlclal leal at SebalUan, ln~the Cot o~f"(~;r . .1A/nFlorlda, the day and yra. MY~N~375724 \ . ~~Al2..~ r.. IJtlf6!!/ .l.. .. ...... .. .. ..... .... fXI'1IlES: Juno 18. lllllll - at. Public, State Florid.. at La~IIje. . _nn-,__ Illy cOmlolalloo rxpl II . Linda M. Galley 1\;/ Name '-117 ;} ,,:) ,_ I . J ill} , ..,.- i-/" 1 J .J' :-; 0 }-..I I " 'u rI, __ _ .f I Unit "I' I Block '.,;: k" . ~ Lot Ayr Date of Mark-out Date of Burial /1/"', . /0 /' / ,..... (,,'. I I f.o Time J () "0,) /-1 ,iY/ . 4-'" c ).~/ . /,'C" ' /.}.;;-' /....,(il; (... Name of Funer,al HO")fr. \) ./ /' Aut'h..,,:::~f7.~':'/7l jf;Y ,.-/' 1/ I. Paid by CEMETERY Receipt No. . .~?~ . . " " " . . Dated. " . ~/?~~~~. " . " ... " ... " lots 23 & 24 1 000 00 Block 36 List Price $ . . . ~ . . . . :. . . . . . . . . Maximum No. Burial Spaces. . . . . . . . . . . . . . . . Uni t 4 . 1,000.00 Net PaId $ .................. Monument permitted. . . . . . . . . . . . . . . . . . . . . . . NO. '1534 (Data above this line lor City Record only) M. Last Thompson A. cJ- 3/ cJ if IJ 3t U1 Month Day 04/24/96 Year [~~] State of Florida, Department of Health and Rehabilitative Services, Vital Statistics APPLlCAe FOR BURIAL - TRANSIT PERMIT . A. 1. Name of Deceased (Type or Print) First Mary Middle DATE OF DEATH Melbourne Name of (If neither. give street address) Hosp. or Inst. Holmes Regional Medical Center Address Phone Number 300 Michigan Avenue Melbourne, Florida 32901 (407)768-1818 Fla. Lie. No./Reg. No. Phone Number (Area Code) 2. Place of Death County Brevard 3. Name of Medical Certifier Asad Shamma, M.D. 4. Name of Funeral Home/ Direct Disposer Strunk Funeral 5. Check Appro- priate Box City, Town or Location ---l Medical Examiner -xj Physician Address 1623 North Central Avenue Homes, P.A. Sebastian, Fl 32958 1228 (407)562-2325 a 0 The medical certification has been completed and signed. A completed certificate of death accompanies this application. b ~ Donna was contacted on 04/25/96 within 72 hours after death. He/she verified that this death w~s from natural causes, that there was no accident nor other external cause of death, and that Asad S amma, M. . 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 Sebast i an Cemetery Final Disposition: 7. Funeral Director/ Indian River F.E. No./Reg. No. ~ 114. Removal from state Donation Date Signed 04/25/96 B. BURIAL - TRANSIT PERMIT Pe 't N 1228-96-0204 rml o. 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. nc!.~;.!t1lU 6F Subregistrar Signature ~~~~d:4f. / ~~/7' Date Certificate Due: C. 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 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: ~BURIAL o CREMATION o STORAGE o OTHER (Specify) Place of Disposition Date of Disposition ~ln-u,r;.it.-v ~-Z ~ .2b,/99,;. 7- I Signature of Sexton ) or Person-In-Charge ) 7J~' \ ,19"._ L 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 edition which may be used) (Stock Number: 5740-000-0326-2) 3.