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Home My WebLink About4-33-26 ------ Paid by CEMETERY Receipt No.. .f; ~.~. . 1,800.00 LIst Price $.. ................ t.800.00:. Net Paid $ .................. 3/21/94 . . . Dated.. .. .. . . . . .. . . . .. . .. . . . .. . .. . . Lots 2~ Block . 26 NO. ~~~ Maximum No. Burial Spaces................. Uni t 4 1453 Q!Uy of &rbusthlU 1453 C!rrmrtrry IIrr~ NO. 21st March 94 A. D~ I......., THIS INDENTURE MADE TIaIa day oi bet,,'een Ihe Clly 0' SebalUan, a municipal ""rporaUon exl.U'.'1! under lhe lawI oi the Slale 0' Florida, .1 Grantor and ........................:..... z.~a~.~.~r~f6g~gR~~tl :.~!!-~l{.<?~.. ~?v.i!!-~l;1.. 9~gr:t.o~..................... ..................... .................... .Bl\~e.f.~~~.. .~l\Y.~.: .~~?~.~~~ J~~!6........................................... ai the Counly of ...India.n..Ri.v.~:C..................... an:1 Slale of .........J:lo.r.:ida................................. as Grantee, WITNESSETH I That the Grantor for and in eonsideratlon of the sum of $ ......\ ,.~9.Q...9q........ to it in hand paid, the receipt whereof is herewith ac- knowledged, does by this instrument grant, bargain, seU, release, eonvey and eonflrm unto the Grantee . .~~.~;i,;- heirs, legal representatives and assigns the following property situated in Sebastian, Indian River County, Florida, to-wit: AU of Lot(s) ?? ~.~ 9 . Block, . ;3, ~. . .. ,UNIT ..;.......... ,of Sebastian municipal cemetery as per Plat Number I thereof reeorded In Plat Book 2, at page 65 of the public reeorda in the ofOce 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 shaU be used solely and exclusively for the Interment of the human dead and shan be used, kept and maintained at an times in acoordance 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 eondltlons, restrictions and requirements eontained In thts instrument shaU be eovehants running with the land. In the event of the failure of the owner of any property situated within said cemetery to ob- ..rve and eomply with Such rules, regulations, resolutions and ordinances and the eondltions of the deed of eonveyance thereof then the title of such owner in and to said property shan terminate and the same shan 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 eorporate ..al to be hereto affixed, the day and year first above written. AU..!: ~~!lJ:.[).~.~. City Clerk CITY OF ~LORIDA BY~'?~ Mayor Slgnl"d, Seftled IInll Delivered In~he Pence of. ....... ~Y'" ....~........... . . . . . . . . .. . . . .. c1.....Ytj. ~ .. . .. .... .. (GIitll ~eal) STATE OF FLORIDA COl'NTY OF INDIAN RIVER I HEUEny CERTIFY, That on this 21st March 94 11... ., . day of ." beiore me personRlly appe.red ..A.:t;.~~~:t;..:r:.... .F.i;r: ~.i.~~......... ......... .... ... and ~~ ~.l:t.:t;Y.~ ..t:'. ~.. ~ ~ .~~ ~~.?F~~. re.p,'etivrly Mayor and Clly Clerk of the Clly of Seb..tI.n, a munlel".1 corporation under lhe In's of lh. Slnte of Florid. to me known to be the indh'iduuls und officers described In flnd who executed the lor('goJng cORveyftnce to Simeon J Gagnon and/or Lavinia Gagnon ....................................................................................................................................... . . . . . . ... . . . . . . . . . . . . . .. . . . . . .. . .. . . ...... .... . ... . . . . .. alld severnlly Rcknowledged the execuUon thereof 10 be their irer. Ret Rnd deed .s sllch o((leer. ther.unto duly .uthorized I .nd that the Ortlel.1 s..1 of .aid corporation la duiy affixed therdo, .nd lhe sold eonvey.nce is th~ nct Ilnd deed oC said corporation. ~v~~ UNOA M.lW.lEY !"i1:oi MY COMMISSION , CC334817 ElCl'IRES 't.' .luna 18 1994 . : ,:t\l _THAU1llIlVFA.-_.INC, WITNESS my .illDature and official ..al at SebasUan, In the IRst .for..ald. Name L_ '~~j ; ;\',) \ i:;~ .,/:',' ,t.:'_"," " - '\..'" A~_) ;~) ;c..) Unit (,,( Block ;..: :'J ,"-' _: Lot (-::~' j,,,"~ Date of Mark-out ; I / .-" i.". "'1 / I ,-- I -; ( . ~ JI.. { J I Date of Burial l~,-i / , f i., J (J f ' I' 0..,,,- '0 " ~ti Time : 1 <:> () /" rt",,\. 4':' .,.. '. ,.', i Name of Funeral Home/""')! ,"'<, \...\,~,) 1\ :~, i // l", '-, ~ .\.~~:-,.. ,.::.<.- . .-/ ."'. " Authorized by,,' . .., '~_;--'".~;"({:.;..l-::,;':' ',' .' it, ..' , / v//: ',:j: ,~'.; 1 l (}J. , . r--- = State of Florida, Department of Health and Rehabilitative S~rvices, Vital Statistics APPLlCATIe=OR BURIAL - TRANSIT PERMIT . j, c? S.-1 /;. I '-. .~. ;g 33 Ij ~/ A. 1. Name of Deceased (Type or Print) First Lavinia Middle Last Gagnon DATE OF DEATH Month Day Year 04/13/96 B. 3. Name of Medical Certifier Noor Merchant, M,O. 4. Name of Funeral Home/ Direct Disposer Strunk Funeral 5. Check Appro- priate Box Barefoot Bay U Medical Examiner Name of Hosp. or Inst. 438 (If neither, give street address) 2. Place of Death County Brevard City, Town or Location M 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. Barefoot Boulevard Address 7744 Bay Street,Suite #2 Sebastian. Florida 32958 (407)589-0879 Fla. Lie. No.1 Reg. No. Phone Number (Area Code) Phone Number b IS.] Pam was contacted on 04/14/96 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 Noor Merchant, M. D. 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 Sebas t i an Final Disposition: 7. Funeral Director/ 9tJ.oc;vl D;\:)J.Jv~t::I~ Indian River Removal from state Donation Date Signed 04/14/96 B. BURIAL - TRANSIT PERMIT P 'tN 1228-96-0190 erml o. 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. Rby;",l,a, 01"- q. to-... - C .. U Subregistrar Signature <:::j ~. l...A... \ '\ " 0 ~-- Date .. \ \ \,., I Issued: _~J '3 '"I'" Date Certificate 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. Methods of Disposition: JW8URIAL o CREMATION o STORAGE o OTHER (Specify) CEMETERY OR CREMATORY . Place of DiSPositiO~&.f ./7.,~ &4~ Date of Disposition ~ ./ I.", . 7 ~ . D. Signature of Sexton ) or P.QCl;QIi1 ili1 Cl>1sfge ) ~-t:;... 1 fl/-t _ .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 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)