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~G.V IG ~ ~ l ~ ~ ~ ~ ~ ~ ~ NO. V ~ ~ ~~~
THIS INDENTURE MADE Tialt .... 2Oth........... day of ......July ................................ A. D.,~..2~~1
between ilse City of 3ebnstlao, a municipal corporation exiat[ng under the laws of the State oP Florida, ns Grantor and
John A. Fredericks.
...................................:...................................................................................................
451 Arbor Street
....................................... S ehas.t i ala., .. El.o~ i da.. 3 29.58................................................... .
of the County ai ........Indian..Riger.,_„...,,,,,,,, ani State of ....Florida ......... .............................
u Grantee, WITNESSETHs
That the Grantor for and in consideration of the sum of $ .l.s. 5 ~ ~ ~ ~ ~ ............. to it in hand paid, the receipt whereof is herewith as
knowledged, does by this instrument grant, bargain, sell, release, convey and confirm unto the Grantee , , , , , , , , , heirs, legal representatives and assigns
the following propertyl ~uateiin~ Sebastian, Indian River County, Florida, to-wit:
All of Lot(s) . ,~, ~ , , ,Block, ... 23.. ,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, Lucie County of Florida; said land now lying and being
is Indian River County; Florda.
To Have and to Hold the same forever; provided that said property shall be.usecl ~lely 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, regulations, resolutions and ordinances and the conditions of the dated of conveyance thereof then the title of such owner
in and to said property shall ternsinate 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.
~. .. ..c ......................
Clty Clerk
in
~. ` P^~~~~nn/
~... /
CITY OF SEBASTIAN, FLORIDA
Mayor
(td~i:~ ~p~!)
STATE OF FLORIDA
COUNTY OF INDIAN RIPER
I FIEREBY CERTIFY, That on this .....20.th........,...day of .......July .......................... ........x~j..2.001
before me personally appeared ....We.lter..W.,.,Barner'.S ........................... ana .S.a~.~,~.~r...~a~.0...............
respectively Mayor and City Clerk of the Citp of Sebastian, a municipal corporation under the laws of the State of Florida to me known
to be tlse individuals and officers described in and who executed the foregoing conveyance to
John A. Fredericks
.......................................................................................................................................
................•....................................... and severally acknowledged the execution thereof to be their free act and deed
as such officers tlsereunto 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 corporation.
Name ~(~ ~ I'~•il ~ ~" ~ -
Unit
Block_~ ".a
Lot _~,
Date of Mark-out
r
/ ~"' t
Date of Burial ~~ I ~ / 't~ ~ Time ~,1 ~ `~'~ `
Name of Funeral Home ~ ~ /'~, 1~
Authorized by
A.
1.
4.
5.
FLORIDA DEPARTMENT OF
HEALT
(TYPE)
Name of
Deceased
2. Place of Death
County
B revs rd
3. Name of Medical
First
Middle
Tina Fa
City, Town or Location
Valkaria
Certifier P ul O. Vesallo, M. D . ,
Medical Examiner Physici;
Name of F I
M • IAddress
f~a 3 -i,~
Last Date Month Day Year
of
Lucas Death July 12 2001
Name of (If neither, give street address)
Hosp. or
Inst. U.S. #1, 25ft south of 3800 U.S. #1
1750 Cedar Street Phone Number
Rockledge, FL 321-633-1981
unera Home/glr~t.9yp~l Address
Establishment Fla. Lic. No./Reg. No. Phone No. (Area Code)
1623 N. Central Ave.
Strunk Funeral Home Sebastian, FL 1228
Check a. The medical certification has been completed and signed. A completed certificate of death accompa8 es th000
Appropriate application.
Box
b.
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that
cert~cation of cause of death within 72 hours. will complete and sign the medical
c ~ was contacted on
He/she verified that
medical cert~cation of cause of death within 72 hours. ~ Medical Examiner, will complete and sign the
6. Funeral Director/ ~ nat
~iror4~~t:,:wir F,E. No./Reg. No. Date Signed
3915 7/12/01
B. BURIAL -TRANSIT PERMIT
Permission is hereby granted to dispose of this body. '
A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted lsince t 01phOysic6ian has
been contacted by the funeral director and will not be able to complete the medical certification of cause-of-death section of the death certificate within
72 hours.
~No extension of time for filing the death certificate has been requested.
~9i~o4
Date Date Certific to
Subregistrar Signature ~ ,
Issued: `~ I Z~ d l Due: "~ ~ 1 O/
~• AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA
Approval Number:
Date
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. Awaiting period of 48 hours after death is
required for all cremations.
D~ CEMETERY OR CREMATORY
Method of Disposition:
Place of Disposition Sebastian Cemetery
BURIAL STORAGE
Date of Disposition _ ~ ~ ~ ~
CREMATION OTHER (Specify)
Signature of Sexton
or Person-in-Charge } ~~ ~ ~ D~
phis 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
vithin 10 days to the local County Health Department in the county where disposition occurred.
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL -TRANSIT PERMIT
~H 326, 6/97 (Obsoletes all previous editions) Distribution: Whke: Comet
hock Number: 5740-000-p326.2) Yellow: Funs Ire D r~or o~Dued Disposer
Pink: Local Registrar