HomeMy WebLinkAbout4-33-14
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Paid by CEMETERY Receipt No... ~.r
List Price S .. ~.~ ~.9~: .q~....
//' Net Pald S ..~.~??~~.~?....
/"
6/24/94 Lots l'
...... Dated.............................. Block
Maximum No. Burial Spaces ............... .Uni t 4
14
NO.
Monument permitted. . . .. .. . .. . . . .. . .. . . . . .
1458
(Data abo~e thla line lor CIty Reeord only)
Q!Ull of &rhu.Htiuu
C!trmrtrry
m r rb
NO.
1458
THIS INDENTURE MADE 11da
24th
day 01
June
94
A. D1 18..,.."
bet.....n II.. City 01 S.bOltlan, . munl.lpal eorpor.tlon ealltlng und.r the l.wI 01 Ihe St.te 01 Florid.. .a Gr.nlor .nd
...."................... ................. .Mr.... WUl.:l.alJl.. ,l,';t;9.v.Q.Efl;..........
674 Periwinkle Drive
.......................................... .Sebastian,.. .Flor.ida. .3.2.958
01 Ihe Counly 01 ....l;n~.:i-.~m..~J~~r..................... .n:1 SI.le 01 ............f)..q~;i,<;l.~...............................
II Granl..... WITNESSETH I
That the Grantor for .nd in considentlon of the sum of S ...~ .'. 9.Q9.: ~9.. :........ to It \hand paid, the receipt whereof Is herewith ac-
knowledged, does by this instrument I!JlInt, bargain, sell, reiease, conyey and confirm unto the Grantee. . . .~::'. .. heirs, lopl representatlyes and ..signs
the following property situated In Sebastian, Indian River County, Florida, to-wit:
All of Lot(s) :': ~.~ ~.4, Block, . .. .~~.. . UNIT ... ~. . . . ... .. ,of Sebastian munldpal cemelery as per Plat Number I thereof recorded In Plat
Book 2, at page 6S of the public records In the ornce of the Clerk of the Circuit Court of St. Lucle County of Florida; said land now lying and being
in Indian Riyer County, FloridL
To Haye 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 herealler 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 such 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 said party of the first part hos 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 aboye written.
AII.~~~/Y?D#~tl<~~......
I City Clerk
CIT:,O~~~
M.yor
and D.lly.r.d
e~. Of.~.,. ~..'.............. ........
." ...z!:.5~........
(Gritl! ""rill)
STATE OF FI.ORmA
COl'N'fV OF INDIAN RTVER
24th June 94
I HEUEBV CERTIFY. Th.t on thla ....................... .d.y 01 .................................................... 18.....
brlore nle perlonally .pp....ed . ..~~~.~.~~..~:.. ~~~.t.i~n........................... and Ka, ~.~.':X~ ..~.... .~. ~ ~~~.~.<?Fa.~...
r"",'ctivrly M.yor .0<1 City Clerk 01 the City 01 Sehullon, 0 munlcl"al cor"ofllllon under the In's of th. State 01 Florid. to me known
to b. the Indll'idu"l. II"d ofllc... described In land who execul"d the I"rrgulng co.y.ynnce 10
Mr. WIlliam Provost
. . . . . .. . . . . . . . . . . . . . . .. .. . . . . . . .. . . . . . . .. .. . .. .. .. . . .. .. .nd severally Rcknowledgrd Ihe execution thereol to be th.lr Ir.. .ct ond deed
os s"eh ofll.... thereunto duly outhorlied t .nd Ihal the Orncl.1 ..nl of s.ld corpDr.llon la duly .Iflxed Ihereto, Rnd the s.ld .onvey.nc.
Is Ihe "et nnd dred of laid corpor.tlon.
.".,r;;'1'.:t1. LINDA M. GALLEY
f~l"j[''''',
W.: "I MY ClMIlSS1llII , CC 375724
. . . 1:XPIllEIl: ./una II, Ill!M1
't.. _11w-'NIIo~
WITNESS
I.st .cor...ld.
Linda M. Galley
Name
J /'IJ' " ;">- '.-
i'-'(J'L..."C<JI" H. r-<o,)y,->,
Unit
J
r
Block
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....0' h")
lot
! cl
; "f"'::;":
Date of Mark-out
to /i;;/')7
! /
I 0 II ~.- / '7 7
/ /
Date of Burial
Name of Fun~~1 HO~'"
,,' '___'__~../:_._~;A"~</
AlIthorized by /'~~./:l:~e, .
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State of Florida, Department of Health, Vital Statistics . ,() L::;}
APPLlC. FOR BURIAL - TRANSIT PERMIT
Iii
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
William H. Provost DEATH Oct. 10, 1997
2. Place of Death
County
I ndian River
3. Name of Medical
Certifier
City, Town or Location
Roseland
Medical Examiner
Name of (If neither, give street address)
Hosp. or
Inst. Sebastian River Medical Center
Address Phone Number
Charles A. Di s,
4. Name of Funeral Home/
Direct Disposer
Strunk Funeral
6. Check
Appro-
priate
Box
M.D., A.M.E
Physician 2500 S. 35th Street, Ft. Pierce, FI 561-464-7378
Addr.e5s Fla. Lic. No./Reg. No. Phone Number (Area Code)
16L.:S N. Central Avenue
Sebastian, FI
1228
561-589-1000
Home
a .3
The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
b 0
was contacted on 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 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
Final Disposition:
7. Funeral Director /
Direct Disposer
I ndian River
F.E. No./Reg. No.
1862
Removal
from state Donation
Date Signed
10/13/97
B.
BURIAL - TRANSIT PERMIT
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.
Permit No. 1228-97-0416
~\,;~;vtl '-41 Ch
Subregistrar Signature
Date I lit. (, . ~ I ... __ Date CertiJlcfa!r It"l...,
Issued:~Due: ~
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:
!bi5tSURIAL
o CREMATION
o STORAGE
o OTHER (Specify)
Place of Disposition
Date of Disposition
tt'~-t;,~ ~$-
~/~ /-:),1'19
/
Signature of Sexton )
or Person-in-Charge) ,-p-..k~....l.- r!/_....L-
This permit must be endorsed by the Secton or pefson-in-charge (or by the Funeral Director/Direct Disposer when thefe is no Sexton)
and returned within 10 days to the local County Health Department in the County where disposition occurred.
DH 326, 10/96 (Replaces HRS Form 326 which may be used)
(Stock Number: 5740-000-0326-2)
5.