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Home My WebLink About4-30-13Name G/i L 614 0" -YX - 1/e$ - Unit Block Lot / ✓ Date of Mark -out Date of Burial �2 8 / Time Pa Name of Funeral Home s+ Authorized by 11/28/2016 17:06 #6201 P.001/001 FUNERAL FOR DIRECTOR'S REQUEST TO C URIAL OPENING IN SEBASTIAN MI ITY OF SEBASTIAN JNICIPAL CEMETERY For information contact Kip Kelso.Cemetery Sex on Sebastian Municipal Cern (772) 589-2545 try City Clerk's Office City Hall, 1225 Main Str Sebastian, FL 32958 Office (772) 388-8215 or 388 4 214 Fax: (772) 589-5570 FUNERAL HOME: 5tr nk Funeral Home and Crematory— SEEBASTIAN Avenue Sebastian. Florida 32958 ADDRESS: 1623 North gentral PHONE#: 772-589-1000 (Check One) xxxxx OPEN BURIAL LOT Lot_13_Blo 30 U iti-q__ OPEN CREMAINS LOT Lot_Block Unit OPEN COLUMB IUM NICHE Niche ck Unit BURIAL DATE AND SER ICE TIME: Thursday, 12/8/2016, 1:00 PM Mass at Sti. Sebastian Catholic Church FOR DECEASED: Elle i L. Clrou Na le NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper cloct imentatiort of ownership) Lori Bennett ZA1 qkwff 11/28/2016 Date Name Signature I certify that I have deterrr ined the ownership of the above describec ite that all Site fges and administrative fees have been paid and authorize opening of same. NAME AND SIGNATURE OF LICENSED FUNERAL DIRECTOR: Gary D. Evans rj�y� Signature 11/28/2016 Date Name Cemetery Sexton Certifi tion' I certify that I have checked the ownership information by viewing th wner's deed anO confirming with Clerk's office and that all fees ha a been paid: Date Ce et Seg ion This form to be provided to Clerk's Office by Sexton for permanent r ord upon com al4tion. FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY 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: Strunk Funeral Home and Crematory–SEBASTIAN ADDRESS: 1623 North Central Avenue, Sebastian, Florida, 32958 PHONE#: 777-589-1000 (Check One) xxxxx OPEN BURIAL LOT OPEN CREMAINS LOT OPEN COLUMBARIUM NICHE Lot-13—Block 30 Unit 4 Lot—Block—Unit Niche Block Unit N S E W BURIAL DATE AND SERVICE TIME: Thursday, 12/8/2016, 1:00 PM Mass at St. Sebastian Catholic Church FOR DECEASED: Ellen L. Cirou 7"iir NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership) Lori Bennett 101E(Pettnett 11/28/2016 Name 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: Gary D. Evans Name Gary Q Evans 11/28/2016 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: Cemetery Sexton Date This form to be provided to Clerk's Office by Sexton for permanent record upon completion. State of Florida, Department of Health, Bureau of Vital Statistics O� BURIAL TRANSIT PERMIT HEALTH DATE PRINTED: November 28, 2016 TRACKING NUMBER: 2016183867 1. DECEDENT INFORMATION Name of Deceased Date of Death ELLEN L CIROU November 25, 2016 Place of Death - County City, Town or Location Name of facility, or street address If not a facility INDIAN RIVER SEBASTIAN SEBASTIAN RIVER MEDICAL CENTER Name and Address of Funeral Home/Direct Disposal Establishment Fla. Lic. No./Reg. No. Phone Number STRUNK FUNERAL HOME- SEBASTIAN F041870 F041870 (772) 589-1000 1623 N CENTRAL AVE SEBASTIAN, FLORIDA, 32958 Funeral Director/Direct Disposer Fla. Lic. No./Reg. No. GARY D. EVANS F065074 2. BURIAL - TRANSIT PERMIT The Florida Department of Health, Bureau of Vital Statistics hereby grants permission to dispose of this body in accordance with Chapter 382, Florida Statutes. Permit Number: 20 November 28, 2 16 03 Date Issued: November 28, 2016 State Registrar 3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL-AT-SEA, or HOSPITAL DISPOSITION Authorization given by Medical Examiner District Approval Number: 4. CEMETERY OR CREMATORY Place of Disposition: SEBASTIAN CEMETERY I� L'I v{- /�l I A Method of Disposition: BURIAL Date of lDiAsp�olsl ioln�: "'/l EDRS maintains all statutorily required information regarding the death record and related burial transit permit, therefore, returning the permit to the county health department is no longer required. if the Place of Final Disposition wishes to retain the copy of the permit for their file they may do so. DH 326E, 10/12 64V-1.011, Florida Administrative Code CITY OF SEBASTIAN 10398 ADMINISTRATIVE SERVICES RECEIPT Name Ur j ( IROLL ❑Cash Date 1r )6Check # 7s63 ❑ Credit Amount Paid 001001 208001 Sales Tax 001001 220000 Security Deposit 001501 362100 Taxable Rent 001501 362150 Non -Taxable Rent 450010 369900 Airport Badge 001001218010 CobraServe 001501 354100 Code Enforcement Fines 001501 347557 Community Center Revenue 001501341920 Copies 001501 351140 Parking Citation 001501 342100 Police Security Services 001501 329200 She Plan Review 001501 329300 Subdivision/Plat Review 001501 329100 Zoning Fees c)oit5 i -3438o5 OIC 150.M �NLT 4 &V -3b DoT 13 Total 1-1 JS • o Initials Security Dep Held - Amount $ Check # White - Dept. of Origin • Yellow - Admin. Svcs. • Pink - Applicant w-ny PI J:9fUU1U1Ult 1!1', ~.4 e<nrmrtrry Irrb. NO. THIS INDENTURE MADE TIaII ....,6. th . ' dRY of ......,.. .J,anuary.. ................ .. ... A, D., w20.0Q between Ihe City of Sebnotlan, a municipal corporation exl.tlng undcr the I.w. of the St.te of Florida, .. Grantor .nd ,.,................................ Philip. .E,. .Cir.ou. .aud/ox.. Ellen. .Cix.Qu.......................... 8006 141st Street " , . ' ........' ... ........................... "Sebas t ian-f' .n,. 32.958.... .... ' , ... ' . .. . . ........ ... ....... . ... .. ..' of the County o' ,l:I:1.o..:i.F\ll. ..R;i, Y:e.:r;.. .. .. .. .. . .. .. .. ...... sn.l St.te o' ........ ..fJ Qr.i.Q.i=!.. .. .. .. .. . . . .. . . .. .. .. . .. . .. . .. . as Gr.ntee, WITNESSETH. That the Grantor for and in consideration of the sum of $ .1... 9.Q9. ~ ~9.... . .. ...... to It in hand paid, the receipt whereof Is herewith ac- knowledged, does by this instrument grant, barg.un, sell, release, convey and confirm unto the Grantee ~.q~. ~ 'F., heirs, legal representatives and assigns the following property situated in Sebastian, Indian River County, Florida, to-wit: All of Lot(s) t~~.~ ~,Block, ..~9.... ,UNIT .~.."...,.,. ,of Sebastian municipal cemetery as per Plat Number I 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, Florids. To Have and to Hold the same forever; provided that said property shall be used soiely and exclusively for the interment of the human dead and shall be used, kept and maintained st sll times in accordance with the rules and regulations, ordinances and resolutions of the City of Sebastian, Florida, hereto- fore, now snd hereafter adopted or provided for tho government and operstion of said cemetery. The conditions, restrictions and requirements contained In this Instrumont shall bo covenants running with tho land, In the event of the falluro of tho ownor of sny property situated within said cemetory to ob- serve and comply with such rules, regulations, resolutions snd 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 nsme and on its behalf by its Mayor and sttested by its City Clerk and its corporate seal to be hereto affixed, the day and yesr fust above written, Alle~, .,~/n,CJ.d~.......... ,t. ~ City Clerk CITY OF SEBASTIAN, FLORIDA cJ B1CJL1~~..... ..... Ma1 Sigm'd, Sealed und Delivered Jn~hep se of. ~. .... .......~c;f..~.... ,..", ...c2.... ......~................... (ClIitl! ~el1l) STATE OF FLORIDA COl'NTY OF INDIAN RIVER I HEilE BY CERTIFY, That on this January 6th 1112.000 ,d.y of ...................................................J before me personally appeared ......qhu.~.~..N~.u.b~~g.~.r......... ... . .ndKa.tl1r.yr..~!..9.'.~~.~~~.~.flr... respt.ctively Mayor and City Clerk of the City ot Sebastian, u municipal corporation umler the laws of th... State of Florida to me known to be the Individuuls and officers described in Gnd who executed the for('gohlg cORveyunce to ..,...."....................... .......... . P.hil ip ,E.... .C.irau. and/.or. .Ellen. .Cirau............................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. and severally acknowledg€'d the execution thereof to be their free act and deed as such officers thereunto duly .uthorlzed; and th.t the Official .eul of .ald poratlon I. duly affixed thereto, ftnd the s.ld conveyunce I. the ftel und de.d of said corporation, WITNESS my signature and official seal at Sebastl.n, In the Count lust .for.sald. UNDA M, GALLEY MY COMMISSION' CO 740478 EXPIRES: June 18, 2002 BoodedThnlNOlIJy__." . . City of Sebastian 1225 Main Street 0 Sebastian, Florida 32958 Telephone (561) 589-5330 0 Fax (561) 589-5570 E-Mail: cityseb@iu.net January 7, 2000 Philip E. Cirou and/or Ellen Cirou 8006 141st Street Sebastian, FL 32958 Dear Mr. & Mrs. Cirou: Enclosed is Cemetery Deed No. 1704 for Lots 13 & 14, Block 30, 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. Jfyou 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 Deparonent of Revenue at (850) 488-9487 for more information regarding the completion of this form. S~m. O-rfaUMA- Kathryn M. O'Halloran, CMC/AAE City Clerk KOH:lmg Enclosures . . THE SEBASTIAN CEMETERY CITY OF SEBASTIAN~ FLORIDA ($( ;JrJ().~ ) ( the lOCk3{) Unit Dollars ($ Terms and Condition 0:[ sale: ~J::?:11 bebillding upon both parties, the seller and !:he purchaser, when approved by the owner 0:[ the property above described. I, or we, agree to purc:hase the abo~e dt:;scribed property on the terms and conditions stated II the forego~ng l.nstrument: " f~ 1 I r; T1ZD~ ~~ The City 0:[ Sebastian agrees the above named purchaser (s) ab7ltrument~ . ./ 1/ '/ //-----------Ci ty or Seb I '1 7/ ~ Y7 L/~'n_ V, / )t~~)~ ~ Wi~ess / / ---- Ci ({){), 7}i /,'p k, ~j 1'1 u1 Ellen '6Cf)(p /4/ ,5 r ~-{- . Seb, FL 3f/:Y6 DJc:cL~) Un(' +-4 Lo~ 13 Lo i- )~ '- -