HomeMy WebLinkAbout4-34-17Paid by CEMETERY Receipt No... ......... Dated ..... 3/8/95 ........ Lots, & 17 ................. Block '34 NO.
List Price 9...1., BQQ, AO.. Maximum No. Burial Spaces .................Unit 4 1
Net Paid $ ...1 , 800 00 .. Monument permitted ....................... + d z: A
(Data above this line for City Record only)
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TP1ItPiPr1� �PPb NO. '1 :1•
THIS INDENTURE MADE This .....8th ........... day of ....... Mar ch ............................. A. D., Ig.95..,
between We City or Sebastian, a municipal corporation existing under the laws of the State of Florida, as Grantor and
Mrs. Linda Petron
.............. ............................... ...... .... ............................ ...............................
624 9maryllis Drive
......................... ......................Barefoot. Bay,.. Flarida..3. 2976........ ...............................
of the County of Indian River aa•1 State of ... Florida
as Grantee, WITNESSETHs
1 800.00 to it ' hand p
That the Grantor for ad in consideration of the turn of $ ..... ? ................ paid, the receipt whereof is herewith ao•
knowiedged, does by this instrument grant, bargain, sell, release, convey and confirm unto the Grantee •�e r ... heirs, legal representatives and assigns
the following property situated in Sebastian, Indian River County, Florida, to-wit:
AB of Lot(s) ,16 & 1 % Block, 34 .. .. UNIT ... 4 ........ .. f Sebastian municipal cemetery as per Plat Number 1 thereof recorded in Plat
Book 2, at page 65 of the public records in the office of the Clerk of the Circuit Court of St. 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 shall be used solely and exclusively for the Interment of the human dead and shall
be used, kept and maintained at all 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 shall be covenants running with the land. In the event of the failure of the owner of any property situated within said cemetery to ob-
serve and comply with inch 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 shall terminate and the same shall revert to the City of Sebastian, Florida.
IN WITNESS WHEREOF, The saki party of the first put 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 affixed, the day and year first above written.
City Clerk
CITY OF SEBASTIAN,
1144.. .... .
M ayor
tifgnrd led uhul Delivered
la tl Pres nee of e
;% '�.... (0tg o*gnl)
f(..t...... ....
STATE OF FLORIDA
COUNTY OF INDIAN RIVER
I HEREBY CERTIFY, That on this ......ath .............dry of ...... March...... ............................... Ig 95,
Arthur L. Firtion Kathryn M. O'Halloran
befure me personally appeared ............................ ............................... and ........ ...............................
respectively Mayor and City Clerk or the Cl ty of Sebastian, r municipal corporatiun under the laws of the State of Florida to me known
to be the hndividuuis and officers described In and who executed the foregoing conveyance to
Mrs. Linda Petron
........................................................................................................ ...............................
......................... ............................... and severally acknowledged the execution thereof to be their free act sod deed
as such officers thereunto duly authorlsedl and that the Official seal of said corporation Is duly affixed thereto, and the said conveyance
Is the net and deal of said corporation. 1
WITNESS my signature and official seal at Sebastian, In the Cq ty o! In n Rlve and State yl)KIr fia, the day and year
last aforesaid. �/ / I 17
pfi'''• LWOA M. GAUZY
:k .; MY COIMrIBBgN /1X197812{
s r Notary Public, State o! FI r Large
����,���' k7F11tiR. im ig, ISIS My c mlasba ezplreas
,S..tr'�' Beaded DoNMMFulgstlsdaasllse Linda M. Galley
IN
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Date of Mark -out -�
Date of Burial% /�f Time
Name of Funeral Home
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STATEMENT: 11
,
Date 4J---
TO a/f / %i%✓1 /� �l
TERMS
IN ACCOUNT WITH
C) "e 7-11
Stock Form 25812
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Stock Form 25812
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
SEBAST
nauoi ►ItKAN tSWWW
For information contact:
Kip Kelso - Cemetery Sexton
Sebastian Municipal Cemetery
(772) 589 -2545
City Clerk's Office
City Hall, 1225 Main Street
Sebastian, FL 32958
Office (772) 388 -8215 or 388 -8214
Fax: (772) 589 -5570
FUNERAL HOME:
ADDRESS: '
PHONE #: /
(Ch ck One)
OPEN BURIAL LOT Lot Block 3f Unit
_OPEN CREMAINS LOT Lot _- _Block Unit
_OPEN COLUMBARIUM NICHE Niche Block Unit
'- W
BURIAL DATE AND SERVICE TIME: // //: oD
r
FOR DECEASED: ,� c,r{,� ,� ,d , a Al
Name
14AME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE:
(Must provide proper documentation of ownership)
Na a Signature Date
I certify that I have determined the ownership of the above described site that all site fees and
administrative fees have been paid and authorize opening of same
NAME AND SIGNATURE OF LICENSED FUNERAL DIRECTOR.
WAZ .
Name Signature Date
Cemetery Sexton Certification:
I certify that I have checked the ownership information by viewing the owner's deed and confirming
with Clerk's office and that all fees have been paid
/�) �_ ", c3i �'A2
Ceqietery exltiri Date
This f0r1T1 to be provided to Clerk's Office by Sexton for permanent record upon completion.
.` Name-
Unit
Block
Lot �
'
Date m Mark-out
_
Time ILA
Date ofBurial
Name ofFun
Aut
T~
-'
___
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
APpro- this application.
priate �-
Box ��'LL�_.r�
b � oA 1- �- Mra� -. was contacted on _.(�;�g�$ 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 Craig De l i gdh , m- D. will complete
and sign the medical certification of cause of death.
c ❑ was contacted on . He /she verified that
Medical Examiner, will complete and sign the
medical certification. - -
6. Place of Sebastian Ceme t In state cemetery/ Removal
Final Disposition: crematory.- na county: Indian River from state Donation
7. Funeral Director/ Signa a F.E. No. /Reg. No. Date Signed
Direct Disposer
B.
BURIAL — TRANSIT PERMIT
Permission is hereby granted to dispose of this body.
Permit No. 1228 -95 -0125
❑ 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.
❑ No extension of time for filing Me death certificate requested.
Registrar or I Date �v,.� Date Certificate
Subregistrar Signature Issued: 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: Place of Disposition
DO BURIAL ❑ STORAGE Date of Disposition �.
El CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person -in- Charge)
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)
State of Florida, Depart of Health and Rehabilitative Services, vitaietistics
t3 /
APPLIC FOR BURIAL — TRANSIT PERMIT
LJ
A. (Type or Print)
1. Dame of First
Middle Last
DATE
Month Day Year
eceased Richard
Davis Petron
OF
03/03/95
2. Place of Death
City, Town or Location Name of
(If neither, give street address)
County
Hosp. or
Brevard
Barefoot Bay Inst. 624
Amaryllis Drive
3. Name of Medical
Certifier
Medical Examiner
Address
Phone Number
Craig Deli dish.M.D.
95 East Sheridan Road
Physician Melbourne Florida 32901
70?7 -,7 /Ff _
(407 )'i5
4. Name of Funeral Home /
Address
Fla. Lic. No. /Reg. No. Phone Number (Area Code)
Direct Disposer
_. . _ _ __
1
1623 North Central Avenu
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
APpro- this application.
priate �-
Box ��'LL�_.r�
b � oA 1- �- Mra� -. was contacted on _.(�;�g�$ 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 Craig De l i gdh , m- D. will complete
and sign the medical certification of cause of death.
c ❑ was contacted on . He /she verified that
Medical Examiner, will complete and sign the
medical certification. - -
6. Place of Sebastian Ceme t In state cemetery/ Removal
Final Disposition: crematory.- na county: Indian River from state Donation
7. Funeral Director/ Signa a F.E. No. /Reg. No. Date Signed
Direct Disposer
B.
BURIAL — TRANSIT PERMIT
Permission is hereby granted to dispose of this body.
Permit No. 1228 -95 -0125
❑ 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.
❑ No extension of time for filing Me death certificate requested.
Registrar or I Date �v,.� Date Certificate
Subregistrar Signature Issued: 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: Place of Disposition
DO BURIAL ❑ STORAGE Date of Disposition �.
El CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person -in- Charge)
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)