HomeMy WebLinkAbout4-35-04
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Paid by CEMETERY Receipt No.. ~i.l:. ........ Dated.... 9/ ?:l.~~................. Lots 1
9 000 00 15,16
List Price S...... ~.....:..... Maximum No. Burial Spaces.................
9,000.00
Net Paid S .................. Monument permitted. .. .. .. . .. . .. . .. .. . ~ . . .
?,3,4,5,6NO.
18,19,20
1469
(Data abon thla line for City Rec:ord only)
QUfy nf &rbastian
.~Qt r m r t r r y
I rrb
"1469
NO.
THIS INDENTURE MADE 'I1oIa
2nd
...................... dAY of
September
94
A. 0.. I.......,
bet.....n .h. City of S.bastlan, a munlelpal eorporatlon ""l.tln. und.r the lawa of the State of Florid.. a. Grantor and
........................ ........... ............... .'!QIJ\IJl'y..&. Ann..Ho1Jl'lch................ ................ ..... ................
206 36th Avenue
................ ..... ................... ..... ... Ver.Q. . Bea.c:h.,. ..Fl0 r-i.aa. .32968.................... .....................
of the County of ......~~~;I,~.~..R:J..v.~1=:.................. anel Slate of ....li'lQr.:t..4a.......................................
u Grantee, WITNBSSETH.
That the Grantor for and in consideration of the sum of S ..~ J.9.Q9. ~ 9.9............ to it in hand paid, the receipt whereof Is herewith ac-
knowledged, does by thi. instrument 'grant, bargaiit, sell, release, convey and confirm unto the Grantee . ~h~.~~ heirs, legal representatives and assigns
tile fqJIOvtins.P. rogertJ sltJlllled jn Jlebis!}an. Indlan Rm.r County, Florida, t<>-wlt:
1,Z,3,4,),b,l),lb, j5lH,19,20 4
AD or Lot(s) ..... " . Blode. . . . . . . .. . UNIT ............. ,of Sebastian municipal cemetery as per Plat Numher 1 thereor recorded In Plat
Book 2, at page 6S or the public recordl In the office or the Clerk or the Cirellit Court or St. Lucie County or Florida; said land now lying and being
in Indian River County, FloridL
To Hive and tn Hold the same rorever; provided that said property shaD be used solely and e"cluslvely ror the interment or the human dead and shall
be used, kept and maintained It aU times in accordance with the rules and regulations, ordinances and resolutions or the City of Sebastian, Florida. hereto-
rore, now and hereafter adopted or proYided ror the go-.oment and operation or said cemetery. The conclltions. restrictions and requlrementl contained
in this instrument shaD be covenants running with the land. In the event of the failure or the owner or any property.sltuated within said cemetery to ob-
serve and comply with inch rules, regulations, resolutions and .ordinances and the conditions of the deed of conveyance thereor then the title or such owner
in and to said property shaD terminate and the same shaD revert to the City of Sebastian, FloridL
IN WITNESS WHEREOF, The said party or the first part has Clused this instrument to be e"eented In It I name and on Its behall by Its Mayor and
attested by its CIly Clerk and Its corporate seal to be hereto affixed, the day and year first above written.
Att..t'o~Jd. .llI. f):;/~~....
?-/7~ CI~6terk
CITYO~~
By~......:.......................
Mayor
Sign...... Sea it nn~ Dellv.red
..... ;,. ...~............
. ....L...1~~.....
(GIitv ~eaJ)
STA'rE OF FT.ORIDA
COl'NTY OF INDIAN RIVER
2nd September 94
I "RUEDY CERTIFY, That on thla ....................... .day of ..................................................., 1.....,
brfore me p.roonally a"peared .... ~~~.~~~ ..~.~.. ~~.~.~ ~~.~. .... .... ... ............. and . ~~.~h~yt:l.. !1.... .Q. 'J!!":~).~~?t:l.
r.."rdlvely Maynr omi City <1erk of the City of SebaRtlan, a munlell.nl eor"oratlon un,l.. the I..... 0' the State of Florida to me known
to b. the Indh'idual. and oWe,," described In und who exeeul.d the 'ort.goln. euaveyanee to
Tommy & Ann Housch
. . . . . . . . . . .. .. .. .. .. . . . .. . .. . .. .. .. .. . .. . . . .. .. .. .. .. ... and .....rally ..know led,..... the execution th.reof to be their Tno act and d.ed
as sneh orflce.. th.r.unto duly authorized I and that the Omeial ...1 of .ald corporallon I. duly affl"ed th.,..,to, and the said conveyance
is th. oct and deed 0' said corporation.
WITNESS my Ilgnoture and off/e1al ...1 at Sobaatlan, in the
last doreaald.
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FLORIDA DEPARTMENT OF
Saf Florida, Department of Health, Vital .sties
APPLICATION FOR BURIAL - TRANSIT PERMIT
/--.1/
18 35'
tl1
A.
1. Name of
Deceased
(TYPE)
First
Middle
Last
Date
of
Death
(If neither, give street address)
Month
Day
Year
Elizabeth
Ann
Housch
8-15-2000
2. Place of Death
County
I ndian River
City, Town or Location
Vero Beach
Name of
Hosp. or
Inst. Palm Garden
of Vero Beach
Phone Number
3. Name of Medical
Certifier Leon Hendley, M.D.
Medical Examiner X
4. Name of Funeral Home/Direct Disposal
Establishment
Strunk Funeral Home
5. Check a. D
Appropriate
Box
Address
36th Street, Ste C
B a h FL 3296
(561) 770-4911
Fla. Lie. No.lReg. No. Phone No. (Area Code)
0130
(561) 562-2325
The medical certification has been completed and signed. A completed certificate of death accompanies this
application.
b. IX]
Kathy was contacted on 8-16- 2000
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. Hendley will complete and sign the medical
certification of cause of death within 72 hours.
6. Funeral Director/
Direct Dispose
was contacted on
He/she verified that
, Medical Examiner, will complete and sign the
of cause of death within 72 hours.
F.E. No.lReg. No.
B.
BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 0130-00-0381
D A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has
been contacted by the funeral director and will not be able to complete the medical certification of cause-of-death section of the death certificate within
72 hours.
~NO extension of time f~lling the death certificate has be~re ested.
Registrar or 0 Date
Subregistrar Signature 0..,. V.J. 0\) ssued:
<X-l"'7-0 '0
Date Certificate
Due: ~ - ~<<.f.....oO
C.
AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT -SEA
Approval Number:
Date
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.
IjBURIAL
DCREMATION
Signature of Sexton
or Person-in-Charge
DSTORAGE
CEMETERY OR CREMATORY
Place of Disposition yA t p,...;!.L;"-J (b/Wlit:J/;;})
Date of Disposition ~ <4. ~ t. d. 0 ;J}. e-o ()
U \
D.
Method of Disposition:
DOTHER (Specify)
} ~Lu,:..) .D. {!~r _ 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 County Health Department in the county where disposition occurred.
DH 326, 8/97 (Obsoletes all previous editions)
(Stock Number: 5740-000-0326-2)
Distribution: White: Cemetery or Crematory
Yellow: Funeral Director or Direct Disposer
Pink: Local Registrar
J
.
INSTRUCTIOI ON HOW TO COMPLETE THE ALlCA TION
FOR BURIAL-TRANSIT PERMIT FORM
. .
APPLICATION FOR PERMIT
Section A.
1. Type name of deceased and date of death.
2. Indicate place of death: County; City, Town, or Location; Hospital or institution (if not in hospital or institution, give street address).
3. Indicate the name, address, and telephone number of the Medical Examiner or physician who is to provide the medical certification of cause of
death.
4. Indicate name,address, telephone number, and license number offuneral home or direct disposal establishment.
5.
Check if a completed death certificate, including the completed and signed medical certification of cause of death, accompanies the pink
copy of the application for Burial-Transit Permit to the Local Registrar of the county in which the death occurred. (If the completed
certificate cannot be obtained in sufficient time to be filed with the pink copy of the Application, check 5b.)
b. Provide the name of the person contacted in an effort to obtain the name of the physician who is to complete and sign the medical
certification portion of the certificate, and the date he/she was contacted. The person contacted must be either the physician or a
responsible person who can speak for him/her.
a.
c. Check to indicate if this is a Medical Examiner case. Give the name of the person contacted who verified that the Medical Examiner will
complete and sign the medical certification of cause of death and the date contact was made.
6. Requires the signature of applicant Funeral Director, FE License number, or Direct Disposer, Registration Number, and the date the Application
was signed.
BURIAL-TRANSIT PERMIT
Section B.
If it is anticipated that the certificate cannot be filed within five days from the date of death, five additional days (exclusive of weekends) may be
requested and granted by checking the box provided. If no extension of time is requested, check appropriate box.
The Registrar or Subregistrar who issues the Burial-Transit Permit will sign and date the Permit Application and assign the permit number. Section
382.006, Florida Statutes, requires that a Burial-Transit Permit be obtained prior to disposition or removal from the State and within five (5) days after
death. It shall be mailed or delivered to the Local Registrar of the county in which death occurred within 24 hours after issuance. NOTE: It is not
necessary to wait until the Funeral DirectorlDirect Disposer has custody of the actual body to begin the paperwork.
AUTHORIZATION FOR CREMATION, DISSECTION, or BURIAL-AT-SEA
Section C.
Approval for cremation, dissection, or burial-at-sea must be authorized by the Medical Examiner. Space for his/her approval number and date are
provided. 1["1 addition space is provided for the name of the person obtaining telephone approval from the Medical Examiner and the date such
approval was obtained.
(NOTE: DO NOT HOLD UP FILING THE PINK COPY WHILE AWAITING MEDICAL EXAMINER APPROVAL.)
CEMETERY OR CREMATORY
Section D.
Required: Signature of Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton.); check the appropriate box to
indicate the method of disposition; fill in the date and place of disposition in space provided