Loading...
HomeMy WebLinkAbout1-38-29 r ~ z y y I\ Y r 0 ~ n x ~ r, ~ m ~ ~ O o ~ r w v t t;~ , ` ' ~ °~ ~ I ~~ ,.~~ ; i ~ ~ 1 ~ Name J ,~ ~ ~ ~ ~ ~ ~! !a ' ~ , F t .. ~ ' Unit ~~ Block ~.+ ., Lot ~'' ~ ~ Date of Mark-out ` ~~ f `~ l Date of Burial ~~' / = ~'"~ .~-`,. /~~,~~ ~ ~ °.~~ri ,. Time f 'r Name of Funeral Home ~ , ~ ~~~~ ~ , r ? , .~ .._.-.- f~- ~`~ ~`' ` ~" ~ ~` ~~ ~`~ , i ~: ,,/ ~' 't Authorized bu' "z '~ ' ~ ~ "" ~"`°~'~ ~`'~~ • `^ OQ~ ~~ Q ~~q 40 CITY OF SEBASTIAN CHECK REQUEST Accounting Use Only Input Date 5/31/2007 Fiscal Period Document # Entered By Document Amount # of Lines otal HC Hash Due Date 4Q To Be Completed By Department ~ ~ 2007 Single Check Y / N Y Vendor Number LN TC Reference Organization Code Object Code Project Code Amount 601011 534959 $300.00 Description Number of Lines Amount Sell back to ci , cemete lots described as Unit 1 Block 38 $300.00 Lots 29 & 30. Co of Deed #545 attached. ISSUE CHECK TO NAME Alberta Clark ADDRESS 809 Gilbert Street CITY Sebastian State FL ZIP CODE 32958 DRAW CHECK FROM SEE BELOW APPROVED BY DATE 5/31/2007 BUDGET APP 0 © MAIL ATTACHED DOCUMENATION (Except for remit slips, requesting department should attach a copy of documentation along with the original) OTHER INSTRUCTIONS Please make copy for clerk ,~ - .'- ~tt~1 Df ~P~tFiBftMlt (~P~t~e#~~r~ ~~e~ed NO. ~ o~.~~ THIS INDENTURE MADE Th1a .....? n d ............ da o! January 8 4 y ............................................. A. D., 18......, between the City of Sebastian, a municipal corporation existing under the laws of the State of Florida, as Grantor and Alberta Clark ....................................................................................................................................... 809 Gilbert St. Sebastian, Florida 32958 ............................................. ............................................ ............................................ of the County. of .,,,.Indian R i v e.r ................... aml State of „ _F 1 o r i d a...........,....,........,...,.,.,...,., as Granter. WITNESSETH: That the Grantor for and in consideration of the sum of $ , 3 0 0 : 0 0 . , , , , , , to it in hand paid, the receipt whereof is herewith ac- knowledged, does by this instrument grant, bargain, sell, release, convey and confirm unto the Grantee , ,her.. , heirs, legal representatives and assigns the following property situated in Sebastian, Indian River County, Florida, to-wit: All of Lot(s) ~ 9 & 3.0~ Block, 3 8, . , , , ,UNIT 1 ..a d d.i t :. ~ of Sebastian municipal cemetery as per t Number 1 thereof recorded in Plat Book 2, at page 65 of the public records in the office of the-Clerk of the Circuit Co of St. Lucie Coun Florida; said land now lying and being in Indian River County, Florida. a ~" v 3~ To Have and to Hold the same forever; provided at said property shall be used solely an ex usivel for the interment f the human dead and shall be used, kept and maintained at all times in accordance with the rules and regulations, ordinances an 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 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 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. tte ~.. .. ....... ~.' ... ........... City Clerk Signed, Sealed and Delivered In the Presence of: `. ...~x..~. ~ .................. . .~..~-n.~.~.. ~..~ ................ CITY OF SEBASTIAN, FLORIDA By .....~~%~~. .. ........... Mayor STATE OF FLORIDA COUNTY OF INDIAN RIVER I HEREBY CERTIFY, That on this ....... 2nd ...........day of .... J a n u a r.y . . ................................ 18 8 4 ., ., before me personally appeared .Pat Flood : J r : and Deborah C . K r a g e s respectively Mayor and Clty 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 eoaveyance to Alberta C1 ark ....................................................................................................................................... ........................................................ and severally acknowledged the execution thereof to be their tree act and deed as such officers thereunto duly authorised; and that the Official seal of said corporation is duly affixed thereto, and the said conveyance to the art an3 deed of said corporation. WITNESS my signature and official seal at Sebastian, in the County of Indian River and State of Florida, the day and year last aforesaid. ~ ... ........ .~.~r . ; ~2;~/ .............. . otary Pub c, 3 of Florida at r My commisdon e:plra: !~ J '~, CLARK, Alberta (Joseph) 809 Gilbert .St. Sebastian, Florida 32958 Lots 29 & 30, Block 38, Joseph interred 1/3/84 Deed #545 Unit Z Addit. r. . ,. _T, :. ~:: ~;<. '~' ;;:; `i ' ;, . . 1 i , Gn 1 CEM ~ex:RECORD # NE4JCEM Record:22 Last Name Address i Address 2 City Deed # Unit # Lot Number Lot Number Lot Humber Lot Number Comment Comment City of Sebastian, FL - Cemetery Lots CLARK First Name ALBERTA 809 GILBERT ST. SEBASTIAN 545 Date i-A Block # 29 Interred 30 Interred Interred Interred CF]wrd CB]ack State FL 01-02-84 Amount 38 CLARKr JOSEPH Ceet] CD]elete CN]ext CP]rec ~ ip $300 32958- Dte Interred 01-03-84 Dte Interred Dte Interred Dte Interred earth CL]abel CT]a~r CEsc] Tuesday, Dec 21, 2004 11:56 AM BLOCK 38 LOTS 29 & 30 Alberta Clark (Joseph) 809 Gilbert St. Sebastian, Florida 32958 Deed #545 Joseph interred 1/3/84 UNIT 1 Addit. Paid by CEMETERY Receipt No.... 3 6.3........ Dated . January . 2 ~ ..19 8 4..... NO. List Price s, 3 0 0. 0 0 Maximum No. Purial Spaces .:?. ... A l b e r t a C l a r k ................. ........ 300.00 Flat 809 Gilbert St. Net Pud S .................. Monument permitted ........ ............ S e b a s t i a n, F l o r i d a Lots 29 & 30, Block 38, Unit 1 Additional (Data atave tbla line for Gty liernrd only) x'54 32958 STATE OF FLORIDA ~ ~ ~~ ~~~ ~~/ ~~ ~PARTMENT OF HEALTH & REHABILITl~E SERVICES VITAL STATISTICS ~ j ~-} APPLICATION FOR BURIAL-TRANSIT PERNIIT A. (Type or Print) 1. Name of First Middle Last DATE Month Day Year j Deceased O F Joseph Aloysius Clark DEATH Jan. 1, 1984 2. Place of Death City, Town or Location Name of (If neither, give street address) County Hosp. or Indian River Roseland Inst. Humana Hospital Sebastian 3. Name of Medical Physician Address Certifier Farhat Khawaja, M.D. Medical Examiner S. U.S. ~~ 1 Sebastian Fla. 32958 4. Funeral Home/ Name Address ps,~.x Pottinger & Son Funeral Home 1200 S. Indian River Drive Sebastian Florida 32958 5. Check a The medical certification has been completed and signed. A completed certificate of death accompanies Appro- this application. priate b ~ was contacted on . He/she verified that Box 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 ~~ ,f Medical Examiner, will complete and sign the %' p ~ , m i I certification. %j (~ e gnature Fla. Lic. No./Reg. No. Date Signed ', ~ ~~yxxx e. BURIAL-TRANSIT PERMIT 759-523 Permit No. 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. If it cannot be filed within this time limit, a "Funeral Director/Direct Disposer Report" will be filed with the Local Reyistrar of the County in which death occurred. Registrar or Sub-Registrar Si Date ~'~-% Issue .~. /~~; 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. D. CEMETERY OR CREMATORY Method of Disposition: Place of Disposition Sebastian Cemetery x~ BURIAL ~ STORAGE Date of Disposition Jan. 3, 1984 CREMATION ~ OTHER (Specify) Signature of Sexton) ~ ~. /1 _a ~ / or Person-in-Charge - Deborah C. Krages ~~~ ~~~ ~l City Clerk v 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 County Health Department in the County where disposition occurred. HRS Form 326, APR. 81 (replaces previous editions which may be used.)