HomeMy WebLinkAbout4-33-18
<!titt! of !;rhustiuu
01813
<trrmrtrry
Urrb
NO.
THIS INDENTURE MADE TIaII
20th
day of ..J~y....................................... A. D.. 19~<;>q~.
between the City of Sebastian, a municipal corporation existing undcr the laws of the State of Florida, as Grantor and
.."..'.. .~~... .~<?~.~~p..l:~~..~P.<?~9.~~Y. ~~. J~.~~. ........ .... ........ .........,................. ... ... ,.....,.. ,..". "..,.
101 Abeto Terrace, Sebastian, Fl 32958
.... .... ..................................... . .... .................. ..................... ... ...... ....... ............................
of the County of .... .~~~~..~y~:r;....................... anJ State of .. .:f~9~~~....... ...................................
as Grantee, WITNESSETH I
That the Grantor for and in consideration of the sum of $ ,;? ?q<?: ~. . . . . . . . . . . . . . . to it in hand paid, the receipt whereof is herewith ac-
knowledged, does by this instrument grant, bargam, sell, release, convey and confmn unto the Grantee . .~f!-!=. . .. heirs, legal representatives and assigns
the following property situated in Sebastian, Indian River County, Florida, to-wit:
All of Lot(s) .. H~ .. ,Block,..;U... ,UNIT ...~......... ,of 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.
This Deed is issued to replace voided Deed No. 1441.
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 such rules, reguladons, 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 fust part 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 fust above written.
y~am- ~
:;:::: .,,~ ':Z~d C~ ~;k H .. H .. H H H. H.
In e Presence of:
CITY OF SEBASTIAN, FLORIDA
BT
.Wo..UM...W.b~l..,....:..,.,
MaTor
.. .~.~...... ....
.,. rfl~. .......... .......
(ClIitU ~eal)
STATE OF FLORIDA
COUNTY OF INDIAN RIVER
20th
I HEUEBY CERTIFY, That on this ....................... .day of
. . .;r~y.. ... . ... . .. . . .... ...,..."....... .. ..... "'J 19~991
before me personally appeared . ~~~.~~~. ~~~.. ............ ................. . .. . .... and .. F!~~~Y..A! ..~~~.................
respectively Mayor and City Clerk of the City of Sebastian, a municipal corporation under the laws of the State of Florida to me known
to be the individuals and officers descrIbed in and who executed the foregoing cORveyance to
.... .~:r:?~~r.~~. .~~1;3.~ ..(~1;3....~<?~~~. .~~~),......... .... ......................................... .........................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. and severn.lly acknowle @ e execution thereof to be thelr free act and deed
as snch officers thereunto duly authorized; and that the Official seal of said co ratio Is duly affixed thereto, and the said conveyance
is the act and deed of said corporation. 9
WITNESS my signature and official seal at Sebastian, In the I n River and State of FI Ida, the day and Tear
last aforesaid. d:
~ AIfOV IlOUllllEMI yty /17_ - -" -.-
Wi :~ MY COMMtSsioNICC725840 . tac;.' PubU~~ St~i~ ';i 'Fi~:~t~~.,.
. EXPIRES: Maldt 18, 2002 My commission expire..
, ,'.. ' llond8d ThnI ~ PubIc UndennIItn
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......~/.1~f.~~.............. Lots 18, 19 & 20 NO.
Block 33
Maximum No. Burial Spaces. . . . . . . . . . . . . . . . Uni t 4
Paid by CEMETERY Receipt Nb.~~. . . . . . . . . . . . . . Dated
List Price $ ...~ I.? ~9. '.9.9...
Not hid $~'"
Monument permitted. . . . . . . . . . . . . . . . . . . . . . .
(Data above this line lor City Reeord ooly)
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1441
J
CITY OF
SEBASTI~N
1225 Main Street, Sebastian, FI 32958
Telephone: (561)589-5330 - Fax (561)589-5570
November 20, 2001
Mrs. Norlin Lust
101 Abeto Terrace
Sebastian, FI 32958
I enclosing Deed No. 01813 which shows ownership of Lot 18, Block 33, Unit 4 at the Sebastian
Cemetery. This is a replacement Deed for Deed No. 1441 that you turned over to the City when
you sold Lots 19 & 20 back to the City.
If you have any questions, please call Ann Rousseau at 589-5330.
ely,
~.l1J- - ~
,.-"
!"
Sally . aio, CMC
City Clerk
SAM/ar
enclosure
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atity nf t;rbustiun
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C!!rmrtrry
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'1441
NO.
THIS INDENTURE MADE TIdI
14th
.. .. ... day of
January
94
A. D., 19.......
between the City of Sebastian, a municipal corporation existing undcr the laws of the State of Florida, 8S Grantor and
..",,'............................ ..Mr... .Nor.lin..Lust...... .... ...... ...........',....,................. ............... ......
101 Abeto Terrace
, . . . . . ..... ... ....................." Se't>as ti.an.,. ..F.lor-ida.. 32.9-5 8...... .... ,',..,......................................
of the County of ...... II:1.d.i. an . E.i. y: e.1;'.. .. .. . .. . . .. .. ... an-] State of .. J': J 9.1;';i, 4~.. .. . .. " .. .. .. .. . .. .. .. . .. .. .. .. .. .. .. . .
u Grantee, WITNESSETH I
That the Grantor for and in consideration of the sum of $ J: 1.~9.Q... 9.Q... ... ..... to it in hand paid, the receipt whereof'
knowledged, does by this instrument grant, bargam, sell, release, convey and confum to t e Grantee . h ~.~ . .. heirs, legal representative
the fOllOn property situated in Sebastian, Indian River unty, Florida, t~wit:
All10dot(~ : .. ~ .. ~ ~ Block, . ;3J.... ,U .. .. . ~.. .. ... ,of Sebastian
Book 2, at page 65 of the public records in e office of the Clerk of the . cuit
in Indian River County, Florida.
To Have and to Hold the same forever; p
be used, kept and maintained at all times in ac
fore, now and hereafter adopted or provided ,~
in this instrument shall be covenants running
20, 2001
II OWNS CEM ERY lOT 18 BUT
TO THE CITY FOR
'p cemetery as per Plat Number 1 th
t. Lucie County of Florida; said Ian
.
IN WITNESS WHEREOF, The said party of the first part 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 st hove written.
Attes~~../71 .... .D.'.M
if City Clerk
J
Signed, Sealed and Delivered
In the P esence of: ~
... . .... ... ... . ... . .. .. .
. ~flt-..~~
,~.. . .'Pc:.....................
(<lIitu ~ea1)
STATE OF FLORIDA
COUNTY OF INDIAN RIVER
I HEREBY CERTIFY, That on this
14th
. . . . . . . . . . . . . . . . day of
January
94
19.. ".
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 'J
Lonnie Powell Kathryn M. O'Halloran
before me personally appeared ...........................................,.......'."..,. and .......................................
respectively Mayor and City Clerk of the City of Sebastian, a municipal corporation under the laws of the State of Florida to me known
to be the individuals and officers described in and who executed the foregoing cORveyance to
Mr. Norlin Lust
... ............................................. ....... ....................................... ............... ..........................
. . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. and severally acknowledged the execution thereof to be their free act and deed
as such officers thereunto duly authorized; and that the Official seal of said corporation Is duly affixed thereto, and the said conveyance
is the act and deed of said co.-poration.
WITNESS my signature and official seal at Sebastian, in the
last aforeaald.
.~~:~. UNDA M. GALLEY
l*: "a'f~ MY COMMISSKW , CC334817 EXPIRES
~'~i June 18, 1994
~.at.t\. . IlONIlEO 1lftJ TROY FAIN INSURANCE,III:.
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/-lr-91
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796
~'
THE SEBASTIAN CEMETERY
CITY OF SEBASTIAN
SEBASTIAN, FLORIDA
Dollars (S ,bZJa fr )
FROM: ~
elo if
\.~~~on, n Cb<q6~
on this I~ffi---- day Of~ Ut:J..r?:&.., , 19 ~ for the purchase of the
following described Cemetery Lot(.S) upon the terms and conditions as
stated herein:
Description of Property: /
Cemetery Lot{SyJ.~ J~di}~ Block ~<33 < Unit.tf
Purchase pric~~~Dollars (S~. p- )
Terms and Condition of sale:
This contract shall be binding upon both parties, the seller and the
purchaser, when approved by the owner of the property above
described.
I, or we, agree to purchase the above described property on the terms
and conditions stated in the foregoing instrument:
#
The City of Sebastian agrees to sell the above mentioned property to
the above named purchaser(s) on the terms and con tions stated in the
above instrument.
/I
// 0./~ /,
k~/.71/.... ~_
//Witness .
(/
\,
CERTIFICATION
STATE OF FLORIDA
COUNTY OF INDIAN RIVER
CITY OF SEBASTIAN
I, Sally A. Maio, City Clerk of the City of Sebastian, Indian River County, Florida do hereby
certify that the attached is a true and correct copy of Cemetery Deed Number 1441 showing that
you still own lot number 18 but sold lots 19 and 20, block 33, unit 4 back to the city for
$1,000.00 which is the amount you paid for them in January, 1994.
IN WITNESS WHEREOF, I hereunto set my hand and affix the Seal of the City of Sebastian
Indian River County, Florida, this 20th day of July, 2001.
~q'rn
City Clerk
.,
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ftECflVf'
CITY OF If'ASTlAN
.FFICE...f CITY eLEIU(
ZDOl JUL 17 PM. 3 00
Dorothy M Lust
101 Abeto Terrace
Sebastian. FL 32958
Tel.# 561-388-2441
July 17,2001
I would like to sell the two cemetery lots that we own, back to the City of Sebastian.
~-?7/~
Dorothy M Luft
Input Date
Document #
Document Amount
CITY OF SEBASTIAN
CHECK RE VEST
Accounting Use Only
Fiscal Period
Entered By
# of Lines Total HC Hash
Due Date
To Be Com~f By Department
7- cP.tJ ~dISing1e Check (!YN
Vendor Number
LN
TC
Document
Reference
Project
Code
Amount
Description
Number of Lines
NAME
ADDRESS
CITY ~PCODE
DRAW CHECK FRO
APPROVED BY
BUDGET APPROVAL (5340
c:::J MAIL ATIACHED DOCUMENATION (Except for remit slips, requesting department should attach
~ a copy of documentation along with the "girIal)
~ OTHER INSTRUCITO S
,
O!itl1 Df l'rbu.stiuu
-
-
Cltrmrtrry
Irrb
.1441
NO.
THIS INDENTURE MADE 'l1IJa
14th
day of
January
94
A. D.. 19......,
.......... '0. ............................. ...
between the City of Sebastian, a municipal corporation existing under the laws of the State of Florida, a8 Grantor and
................ ........ ...... ... ....Mr...,Nar.lin..Lust..... .... ..... .................. .... ........ ... ... .....,........, .,..,.
101 Abeto Terrace
....,... .'...... ..... ....,...,..,..",Se-1:>asti.an.,.. .F.lor-i.da..3Z,9.58.......... ....................... ............. .... ....
of the County of .... ..l.n.d.:i.an. . E;i, v: ex . .. .. .. .. .. .. .. ... an-J State of .. El.9.J;;i, 4~.. .. . .. . .. .. . .. . .. . .. .. .. .. .. .. .. . .. .. . ..
II Grantee, WITNESSETH I
Tbat the Grantor for and in consideration of the sum of $ .~ 1.~ 9.9... 9.Q . . . . . . . . . . . . . to it in band paid, the receipt whereof is herewith ac-
knowledged, does by this instrument grant, bargam, sell, release, convey and conIum unto the Grantee . h f.~ . .. heirs, legal representatives and agsigns
the fOllO~ property situated in Sebastian, Indian River County, Florida, to-wit:
All ~f Cot(~ : . . ~. . ~? Block, . ;3. ~ . . .. ,UNIT .....~....... ,of Sebastian municipal cemetery as per Plat Number 1 thereof recorded in Plat
Book 2, at page 6S of the public records in theoftice of the Clerk of the Circuit Court of St. Lucie County of Florida; said land now lying and being
in Indian River County, Florida.
NOTE: JULY 2~, 2001
MRS. lUST STIll OWNS CEMETERY lOT 18 BUT lOTS 19 & 20 HAVE
BEEN SOLD BACK TO THE CITY FOR $1,000.00 ..
. 21jt2.),j-:4~4ad,/ ~
To Have and to Hold the same forever; provided that said property shall be used solely and exc1usi~ interment of the ~ dead and shall
be used, kept and maintained at all timeg 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 such rules, regulations, resolutions and .ordinances and the conditions of the de'ed 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 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 aflned, the day and year lust above written.
,..~/ {'\/~,r,
..' . I -. ,
:...; , '. I a~ .' .
Attest. .. 0::-L..It,~..)71... ........ .l.t....t.-t..-U...--..
I City Clerk
Signed, Sealed and Delivered
In the P sence of I /
/ / .
,~~.-..~~~~7:...............
.?/..9~..,..............
(ClIitv ~eaJ)
STATE OF FLORIDA
COUNTY OF INDIAN RIVER
14th
I HEREBY CERTIFY, That on thiB ....................... .day of
January
94
19.. ..,
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 'J
before me personally appeared... .~.<?~!l:f.~.. ~~.. .~~~~.~~.....,...................,' and .. ~~ ~.l?-.:r;Y.!l:. .~.... .9, ~ ~~~+.<?;t;'~~
respectively Mayor and City Clerk of the CIty of Sebastian, a municipal corporation under the la\1"s of the State of Florida to me known
to be the Individuals and officers described In and who executed the forl'going cORveyance to
Mr. Norlin Lust
.. ....... .......................................................................................... .....................................
. . ,. . ... . . . . . . .. . . . .. . ... .. .. ... ... ............ .. ,. ... .. and severally acknowledged the execution thereof to be their free aet and deed
as such officers thereunto duly authorized; and that the Official seal of said corporation Is duly affixed thereto. and the said conveyance
is the act ond deed of said corporation.
WITNESS my signature and offlclal seal at Sebastian, In the
last aforesaid.
oIo!>::"'h::t" UNDA M ft... ""
.~~' . :'T/;. . lIlII'U.U; f
f*: :4 MY COfoIISSKr4 , CC334817 EXPIRES
~~ . ~ .II.nl18 1994
~ifI::nl,'" lIONIIElI11RI TllOY FMtIHlMlANcE,II<<:.
.~
Paid bYCEM7R;;;:;l~;3.,....... Dated......\ 1.lfJ.t.~~.............. i~~~1.
LhtPrice S.. ..J... ..,.oo..... Maximum No. BurlalSpacea., ...... ..... ... Unit ~
Net Paid S ...~!. ~~~.: ~?oo. Monument permitted.......................
19 & 20 NO.
, 1441
~ '
(D.t. .......e thl. line lor CIty Reeord ouly)
C!!Ug nf &thU.Htiutt
Clttttttftry
It,ll
1441
NO.
THIS INDENTURE MADE TIoIa
14th
....,,,, day 01
January
94
A, D1 18.......
....................:.........................
bet"'ern I"e CIty 01 8ebaatl.n, . IDUnlelpal eorpor.tlou exlat.... under the I.WI 01 the St.te .t FIorlel.. .a Grantor .nd
"'.....'........"".......... ,Mr.,. .Nar.lin..Lust..,........................",.".,..........,.... .....................
101 Abeto Terrace
, . . . .. .. . ........ .... ........... Se9a8 t lan.,.. .F-lar-i-da. ,32-9.58.. .. .... .. "',.,',........,...,...............,...,..,
of the CoutT 01 ...... I.n.d.i.an. .IU, Y:e.L.......oo....... .nJ SI.te 01 .. r.l.Q,J; ;l,q~...................... ' ..... ......... '...
aa G..nt..... WITNB8SETH I
That the Grantor for and In consideration of the sum of S .~ I.~~Q... 9.Q...... ....... to It in hand paid. the receipt whereof Is herewith ac-
knowledged, does hy thhinstrument JUnt. ba...m. ..0, relea.., con..y and confirm unto the Grantee . ht~ ... heln,......1 repreaentat.... and .sslgns
the followl1 property situated In Sebllllan, Indian Riftr County, Florida. t.....lt:
AO ~f lot(~ ~ . ,~. . ~? Blodt. . ;3.:}. . .. ,UNIT "...~....... ,of Sebastian municipal cemetery 81 per Plat Numher I thereof recorded In PIal
Book 2, at ..... 6S of the pubHc records in the offtce of the Clerk of the CIrcuit Court of St. Lucie County of Florid.; Did land now Iyinc.nd being
In Indian R... County. Florida.
To Hue and to HoIeI the _ fore_: proYlded that said property ahaU be uled IIlIeI)' and elleluslvely for the Intef1llOllt of the human dead and shoO
be used, kept and maintained .t an tImea In accorda_ with the rulea and reaulatlona, ordlnancea .nd Jellllutlona 01 tile City of Sebastian, Florida. hereto-
fore, no... and "-fter adopted or prO'fIded for the IOftfll1ItelIt IUcI operation of said eemetery. The concllt1on.. Jellrictlona .nd reqalremenll contained
In this instrument shaD be co\'enanta running with the land. In the event of the failure of the owner of any property attuated within said cemetery to ob-
serve IUd comply with iud! rules, reaulatlons, rewolutlon. .nd ,orcllnances and the conditione 01 the deed of con..yaneo the_f then the title of such owner
in .nd to said property aban terminate and the same IlhaR reftrt to the City of Sebastian. Florida.
IN WITNESS WHEREOF, The DId party of the first part has caused this Instrument to be ellecuted in Its name and on Its behalf by Its M.yor and
.ttested hy III City Clerk IUd Its corporate ...1 to be hereto aI1lll64. the cI.y and year f1rst .ho"" written.
j
A tied.
)a:~4U~. In ,',. .{):Ilal.l~u,,--
/ City C1ertr
Ili,nrd, Sealed .nd Delivered
7}E;n the P oil /
)','~ ,~>f.-fr...-r;j.~?'~~7...............
,y,,9~f:*.~~.................
(Qtill! ,$flll)
STATE OF FLORIDA
COl'NTY OF INDIAN RIVER 4
1 th January 94
I HEREBY CERTIFY, 11tat on !hI. ..............."..... ..d.y 01 ,..,..,"........................................ ,,' 18,.."
brf".. me peraon.11y .ppe.red ... .~.<?~~~.~.. ~ ~. ..~~~~,~ ~ . .. .. , , __ , .. .. .. __ __. .nd .. ~~ ~.J:1?:y.~ . .l:f. ~ .. ~ ~ ~~ ~ ~.C?r: ~~
rea",,,,tlyrly M.yor .nd City C1.rk 01 the ClI)' 01 8ehaatl.n, a munlel,..1 mrpnr.tlon under the I...a of the Stale 01 F1orlel. to me known
10 be lite lndiYidunl. and orllern deIC:rlbed In .nd who neeul.od the lorl....lnl "".yey.nee to
Mr. Norlin Lust
...................................................................................................................................
, . .. , .. . .. .. .. .. . .. .. .. . .. .. .. . .. ' .. .. .. .. .. . .. .. .. .... .nd ......rally acknowledg.... the exeeutlon thereol to IN! their Iree ..t and deed
.. au.'" offleers tller.unto duly .ulhorlaedl and that the 0111.1.1 ....1 of ..Id ...rporallou Ie duly .ffllled thereto, .nd the said ...nyey.ne.
I. the net .nd deed 01 saki eorpor.tlon.
WITNESS ...,. "m.hlre and offlcl.1 _I at Sehaatl.n. In the
last aforeuld.
G) I.INIM M.IW.I..EY
., : MY IBIlISSIlIII '1:C3l4lI17 EllPIAES
.- tt, ...
_____.11:,
, . ~. .
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.
.
City of Sebastian
1225 MAIN STREET C SEBASTIAN, FLORIDA 32958
TELEPHONE (407) 589-5330 C FAX (407) 589-5570
January 24, 1994
Mr. Norlin Lust
101 Abeto Terrace
Sebastian, Florida 32958
Dear Mr. Norlin:
~.
Enclosed is Cemetery Deed No. 1441 for Cemetery Lots 18, 19 and
20, Block 33, Unit 4.
Also enclosed is a form - Return for Transfers of Interest in
Florida Real Property - which must be filled out by you and
completed by the office of the Clerk of the circuit Court when
and if you have the deed recorded. If you wish to have this deed
recorded you may do ISO at the office of the Clerk of the Circuit
Court, 2145 14th Avenue, Vero Beach, Florida.
We are enclosing two copies of Receipt No. 793 and ask that you
sign and return to us the copy marked with an "X" and retain
the other copy for your records. A stamped, self-addressed
envelope is provided for your convenience... ~..
..
ve!! ~uly yours,
'KtUly...~;m. t)1/dI#lA..
Kathryn M. O'Halloran
City Clerk
KMO: lmg
enclosure
(\ws-form-cem.rec)
C'tlt::..~.~-:S
.
.
796
THE SEBASTIAN CEME.1'ERY
CITY OF SEBASTIAN
SEBASTIAN, FLORIDA
Dollars ($~t? ~ )
FROM: ~
e/.o
,-9~~t1f)1 n ~q6~ .
on this I~:ffi,- day Of~U4r~. 19!1d for the purchase of the
following described Cemetery Lot~r~upon the terms and conditions as
stated herein:
~ .
Description of Property: ~
Cemetery Lot(~~_ rTn1.t
Purchase Pric : '-I.' ~ Dollars ($~. p.- )
Terms and Condition of sale:
This contract shalL be binding upon both parties. the seller and the
purchaser. when approved by the owner of the property above
described.
I. or we. agree to purchase the above described property on the terms
and conditions stated in. the foregoing instrument:
t
7J~L'-R1~
The City of Sebastian agrees to sell the above mentioned property to
the above named purChaser ( s) on the terms and con tions st:ated in t:he
above instrument:.
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State of Florida, Depart~of Health and Rehabilitative Services, Vita.istics
APPLlCA'B FOR BURIAL - TRANSIT PERMIT
J.. /8
~33
t/~
A.
1. Name of
Deceased
(Type or Print)
First
Daniel
Middle
Last
Lust
DATE
OF
DEATH
Month Day
01/10/1994
Year
2. Place of Death
County
Brevard
3, Name of Medical
Certifier
Basil Theodotou,
4. Name of Funeral Home/
Direct Disposer
Strunk Funeral
5. Check
Appro-
priate
Box
City, Town or Location
Medical Examiner
Name of (If neither, give street address)
Hosp. or
Inst. Holmes Regional Medical Center
Address Phone Number
1601 South Apollo Boulevard
Melbourne, Florida 32901 (407)951-0022
Fla. Lic, No./Reg. No. Phone Number (Area Code)
Melbourne
M.D.
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 IJ
Pat was contacted on 01/11/199~ithin 72
hours after death. He/she verified that this death was from natural causes, that there was no accident
norothef external cause of death, and that Basil Theodotou, M.D. will complete
and sign the medical certification of cause of death.
c 0
medical certification.
was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
6. Place of Sebastian
Final Disposition:
7. Funeral Director /
Direct Disposer
Indian River
F.E. No./Reg. No.
1672
Removal
from state Donation
Date Signed
01/11/1994
B.
BURIAL - TRANSIT PERMIT
Permit No. 1228-94-0014
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 e death certificate requested,
Registrar or ,e. '/
Subregistrar Signature ~
Date
Issued:
/- II. 9'1
Date Certificate
Due:
C.
AUTHORIZATION for CREMATION, DISSECTION or BURIAL -AT-SEA
Signature , Medical Examiner Date
or
Medical Examiner, . gave authorization by telephone fo
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:
i!;I BURIAL
o CREMATION
o STORAGE
o OTHER (Specify)
Place of DispOSition
Date of DispOSition
-4~1L~'., /iV1i/U"1
~I ,.~/ .;:j" ()
Signature of Sexton )
. or Person-in-Charge) ..J;'L., ", \
,i ict..>"..rA..
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