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Home My WebLink About4-31-12eTt#u at orhaottttri *Pmetery OPPA NO. THIS INDENTURE MADE This .... 31AL............ day of ... May .................... A. D, WWQ between the City of Sebastian, a municipal corporation existing under the laws of the State of Florida, as Grantor and St�P,x. J, . KQz1owskl .................... ............................... .. . . ........ 605 Collins Street .............. ............................... Se6mtsan,..FL . 32958.............................. ............................... of the County of ... Pi 4C ri RIVer ...... I ..... and State of .......... ..............Florida.......... ........ as Grantee, WITNESSETHu That the Grantor for and in consideration of the sum of $ 650.00 ................. to it in hand paid, the receipt whereof is herewith ac- knowledged, does by this Instrument grant, bargain, sell, rel ease, convey and confirm unto the Grantee , 8 ... heirs, legal representatives and assigns the following property situated in Sebastian, Indian River County, Florida, to -wit: All " 12. Bmck,31East UNIT 4 ........... , 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. Lude 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 shell 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, regulatlons, resolutions and ordinances and the conditions of the deed of conveyance thereof then the title of such owner in and to said property doll 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 affixed, the day and year first above written. CITY OF SEBASTIAN, FLORIDA Attests . i./..1. J. . .... .. . ... By . !!l.l.aX.� ...Y.Y.. W`!! 'P ............ City Clerk Mayor Signed, Sea an Delivered 41nner ................. Mau 10"1) .... ......................... ..... 4 STATE OF FLORIDA COUNTY OF INDIAN RIVER I HEREBY CERTIFY, That on this ......31.$x ............day of ............. JftY ................................. , 74112.000 Walter W. Barnes h �,,, before me personally appeared ......................... ............................... and K$t•" J.ia.M .. P.'Wlorari. .... respectively Mayor and City Clerk of the City of Sebastian, s 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 conveyance to Stanley J...KQzlowgki ............. and severally acknowledged the execution thereof to be their free act and deed ea such officers thereunto duly authorised; and that the Official seal of said corporation is duly affix ereto, and the said conveyance is the act and deed of said corporation. WITNESS my signature and official seal at Sebastian, In the County ¢t I�er 8tatc o Florida, th day and year lest aforesaid ��\ —.- .�. �rCC7�047g otary u G Si orids, at Large. Baj,l EXPLIES:&Nlelaw My commies e Uissssulnu t Name V 0t�v.? y t� Unit Block ... , Lot r ! Date of Mark -out Date of Burial I f/1 Time Name of Funeral ome Authorized by o m •Zi zZ ww (oWff w(� ww N O y O O O O O S ` S m m W m r v c 03 m v, ff CD I .°. .� CDD Q D m wi C N R Cn C) A a 0) a n ; CO CA W 'a O N 5 "n -� m M .o a O1 n at a W o S LR CL O '� 18 fit rr�mou+ nv`wrra� 1700 WATERFORD DR. APT. 225 634/630 FLr VERO BEACH, FL X2966 -8046` / 1064 Date 1 j �j `7 Pa :. 6 6 to Y e order ollars a Bank'OAFfidfica iGn® f ACH R/r 083100277 ' t 5 °mod M mo ,N. 06300 'r 0 0 tj �: 00 3 388 s 138 7811' 2 3 2 5 Paid by CEMETERY Receipt No.. . Dated .. 5/26/00 • ........ List Price $ , 650.00 ..... ............. .............. Net Paid $ .¢?.Q: QQ .... .... Maximum No. Burial Spaces .................. N0. Monument permitted (Data above this line for City Record only) • Q �fF 5 P OF pFLICAN City of Sebastian 1225 MAIN STREET o SEBASTIAN, FLORIDA 32958 TELEPHONE (561) 589 -5330 o FAX (561) 589 -5570 June 2, 2000 Stanley J. Kozlowski 605 Collins Street Sebastian, FL 32958 Dear Mr. Kozlowski: Enclosed is Cemetery Deed No. 1733 for Niche 12, Block 31 East, Unit 4. Also enclosed is a form - Return for Transfers of Interest in 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 so at the office of the Clerk of the Circuit Court, P. O. Box 1028, Vero Beach, Florida 32960 or you may call or call the Department of Revenue at (904) 488 -9487 for more information regarding the completion of this form. We are enclosing two copies of each the receipt 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. Sincerely �n- O"Am%- Kathryn M. O'Halloran, CMC /AAE City Clerk KOH:Img Enclosures I& Sebastian Cemet^ City of Sebastian, Florida I � J . r Me ..��.•a Description of Property: Cemetery Purchase Terms and Condition of Sale: 1 �of- Dollars (1 , 20_10 for the purchase of the following upon the terms and conditions as stated herein: I:. 7 Dollars ($ 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 instnunent: X 4 Purchaser signat e Purchaser signature The City of Sebastian agrees to sell the above mentioned property to the above named in the above instrument. tness — State of Florida, Department of Health and Rehabilitative Services, Vital Statistics APPLICATION FOR BURIAL — TRANSIT PERMIT A (Type or Print) 1. Name of First Middle Last DATE Month Day Year Deceased Stanley Joseph Kozlowski OF Sept. 3, 1995 DEATH 2. Place of Death City, Town or Location Name of (If neither, give street address) County Hosp. or Indian River Sebastian Inst.605 Collins Street 3. Name of Medical Medical Examiner Address Phone Number Certifier 7744 Bay St. Noor Merchant, M.D. Physician Sebastian Fl. 32958 407 589 -0879 4. Name of Funeral Home/ Address Fla. Lic. No. /Reg. No. Phone Number (Area Code) Direct Disposer 953 Old Dixie B -6 Indian River Cremations, Inc. Vero Beach, Fl. 32960 KB0000235 407 234 -5961 5 Check Appro- priate Box W The medical certification has been completed and signed. A completed certificate of death accompanies this application. b ❑ 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 ❑ was contacted on . He /she verified that , Medical Examiner, will complete and sign the medical certification. 6. Place of In state cemetery/ Gulf Cremations Removal Final Disposition: FRI cremator - name /county: palm Beach County from state Donation 7. Funeral Director / J • Signat I J F.E. No. /Reg. No. Date Signed Direct Disposer ,ti KA0000235 9 -4 -95 B. BURIAL — TRANSIT PERMIT Permit No. 195 -95 -143 t Permission is hereby granted to dispose of this body. ❑ 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. ER No extension of time for filing t qi ath certificate req ed. _ Registrar or Date //jj� ate Certificate Subregistrar Signature Issued: —L Due: C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL— AT— SEACremation Authorizatio Signature Medical Examiner Date or Medical Examiner, Frederick Hobin, M.D. gave authorization by telephone to Paul Goodridcge Funeral Director /Direct Disposer. Date 9 -1)—q6 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 P �— Methods of Disposition: Place of Disposition ❑ BUFF lAL ❑ STORAGE Date of Disposition 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)