HomeMy WebLinkAbout4-34-10
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Paid by CEMETERY Receipt No. . . .~?- 0
Lbt Price S.. ~! .~9.q ...9~...
Net Paid S .. ~ ~ .~?~ :.?~...
.......Dated.....~.(~?/?~.............~ots 9 F- 10
Block 3
Maximum No. Burial Spaces .............. Uni t 4
NO.
/
Monument permitted . .. . . . .. .. . .. . .. . .. .. . .
1468
(Data aboye this line 'or C1t, R4!e0rd only)
((tUy nf &,hastiau
<1!rmrtrry mrrb
1468
NO.
THIS INDENTURE MADE 'I1oIa
26th
d.y 01
August
94
A. D~ 1.......,
bet,,'een the City 01 S.blUtlan, a munlelpal eorpo.atlon eal.tin. under the lawa 0' the State 0' Florida, aa Grantor and
".".....,....... .... ...... ........ ..Ml'... ..Edmund..C.... Po.lakQw.ski.. ..........,.,.................. ......... ............
1018 S. Wren Circle
.',.,... ...... ... .:............... ....Bar.efoot,. Bay.,..FLg.r-ida ..3297.6.... ..,....'............ ...... ........... .......
01 the Count, 0' ..+.~~;i~.~.. R~.y.~;r::...................... ani State 0' ];I,~:t:'.:j.fl~.........................................
II Grantee, WITNESSETH.
That the Grllltor for and bt consideration of the sum of S ~... ~R9.: ~9........ ...... to it in hllld paid, the receipt whereof Is herewith ac-
knowledged, does by this instrument 'grant, barplit. ..II, re....., convey and confirm unto the Orantee .. h~ ~ .. heks, lop' reproaentatives IIId assigns
the foUowing property situated in Sebastian, Indian RiYer County, Florida, to-wlt:
All of Lot(s) .~ ~.~ ~ ,Block,.~;..... ,UNIT ...~......... ,of Sebastian munldpal cemetery II per Plat Number I thereof recorded In Plat
Book 2, at PlI8" 65 of the pub6c records In the omce of the Clerk of the Ckcult Court of 51. Lucie County of Florida; Midland now Iylngllld being
bt Indllll River County, Florid..
To Have and to Hold the .me forever; proYided that Mid property shan be used IOlely and exclusiwly for the interment ofthe humlll dead and shall
be used, kept and mabttained 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 Mid cemetery. The conditions, restrictions IIId requkements contained
bt this instrument shan be covenants runninll with the land. In the ....nt of the failure of the owner or lilY property situated withbt .Id cemetery to ob-
..rve IIId comply with iuch rules, regulations, resolutions and ,ordinances and the conditions of the deed of conwYlllCe thereof then the title of such owner
in and to .Id property shan terminate and the .me shall revert to the City of Sebastian, Florida.
IN WITNESS WHEREOF, The Mid party of the first part has caused thb instrument to be executed in Its name IIId on Its behalf by Its Mayor and
attested by ita City Clerk IIId its corporate ..a! to be hereto afOxed, the day and year first aboVe written.
All::::~!<. .... ..lJ.7. C)#~.......
,;;;7, ~ City C1e.k
aTY1ZJ(J~
Mayor
Slp..I, Seol'" Ulld Dellye..d
~-:"~d*................
ytLit.1~H
STATE OF FI.ORIDA
COl'NTY OF INDIAN RIVER
26th August 94
I HEIlEBY CERTIFY, That on thla ....................... .day n' ,...................................................f 1.....,
brio.. me pmonally appeared .~.~~~.':1.~.. ~~.. !~~.~.~~~............... ...... .... ... and Ka.~.I:t!;y.~. M.... .9. ~ ff~P.<?!;~~...
...pretively Mayo. olld City Clerk 0' tho City 0' Sebastian, I munlell.al eo.po.aUon un.l.r the I..." 0' th. State 0' Florida to me known
10 be Ihe Indlvi"ual. nlld offlee.s .....rlbed In ond who exeeutl..! the 'orrlJ01nll ....ny.nee to
Mr. Edmund C. Polakowski
(GIitv .,seal)
.......................................................................................................................................
. . . . . . .. . . . . . .. .. . . . . . . . . .. .. . .. . .. .. .. .. .. .. . .. .. .. .. .. and .eyera!ly aeknowledg<'d the exeeuUon thoren' to be their 'reo aet Inti deed
as sueh offle... the.euuto duly authorlsed I and that the Official ....1 0' uld "".puraUon la "uly amxed thereto, .nd the Hid eonnya...,.
I. the .et .nd "oed of uld eorporation.
WITNESS my .Ipalure and of'lelal .... at 8eba.tlan, In the p>unly 0
last oIo.oaald.
~ UNOA M.1W.i.EY
W~. III ~~ IIYCJlMMI8llIltl'lXllmt4
. EllPlIlEB: ..... II, 1.
. .......1lnr -, NIt........
[lIJ.~]
State of Florida, Departm.f Health and Rehabilitative Services. Vital.~stics
APPLICAT FOR BURIAL - TRANSIT PERMIT
I- 9/ lZ/
/3~3 /1
Ii 1
A.
1. Name of
Deceased
(Type or Print)
First
Sylvia
Middle
Last
Polakowski
DATE
OF
DEATH
Month Day Year
08/23/94
M.
West Melbourne
Medical Examiner
Name of (If neither, give street address)
Hosp. or
Inst. We
Phone Number
2. Place of Death
County
Brevard
3. Name of Medical
Certifier
John Liebler M.D.
4. Name of Funeral Home/
Direct Disposer
City, Town or Location
Physician
Address
Strunk Funeral
5. Check
Appro-
priate
Box
Homes
a D
1623 North central
P.A. Seba tian F 3 9 ~ ~-? ~
The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
b lJ:
U~ra was contacted on 08;2'1/91 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 Tnhn T; ph 1 PT, M n will complete
and sign the medical certification of cause of death.
was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
c D
medical certification.
6. Place of Sebast ian
Final Disposition:
7. Funeral Director /
Dh;pr.t m:;pnser
--
Indian River
F.E. No.l~.
Removal
from state
Donation
Date Signed
B.
BURIAL - TRANSIT PERMIT
Permit No.
1228-94-0404
Permission is hereby granted to dispose of this body.
D 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.
D No extension of time for filin the death certificate requested.
Registrar or -;-
Subregistrar Signature / ~
Date t:7" ~ J ~ 1 Date Certificate 0
Issued: ; -'7"-/7 Due: t7-
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:
~ BURIAL
D CREMATION
D STORAGE
D OTHER (Specify)
Place of Disposition
Date of Disposition
J.. J-j:-- !l~_J ~
/J~J" ~ ~b /994
,
Signature of Sexton )
or Person-in-Charge) ...J/ /..~ J. ~
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)
T
Name
<; . L" \,' ..,
__ y ~' v I ).t
<I
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'/"/0 r M ,< .,j
u)
i,"/ ......~~...........,-
~) I~~' .L~,
Unit
Block
~.> I'
:) . ~(~
Lot
/D
Date of Mark-out
,/ /
t> / ~'j, (I I (', 1../
< .~'_'f / '/'
Date of Bu rial
r, I
"'",." I
.,......' .
..i:,~" ;,;.,..'
/ ;,,1 c; .(/
Time
./ to)
:C..' 0 If" w)
Name of Funeral Home -.-) r/-::
1'7
Au!h.,',ed by O~;:: L;[;v
V"
(,1'."".' ,/( .
4->7
,/;,::::,":>'/",
." / ,,,....
-Oo / .{;(>- ',/ - 0"
//~ .,...../
/
:r
Paid by CEMETERY Receipt No 820 8/26/ 4
. ...... ......... . Dated.. .. ... .. ... 9 Lo t s 9 & 10
ListPrice$..~.~.800.00 .................B.lock 34
. . . . . . . . . . . . Maximum No. Burial S
Net Paid $ 1 , 800 . 00 paces........... ... Uni t 4
~2.::::p~Mon=~t--tt.........................
(Data above this line for City Record only)
NO.
1468