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THIS INDENTURE MADE This ....$TH ............. day of ......... APRIL ............................ A. D., W..2002
between the City of Sebastian, a municipal corporation existing under the laws. of the State of Florida, as Grantor and
HYN
.................. ............................... P EL WOJTAN
, ........................... ...............................
.O. BOX �780989�
........................................... ......S EBAS T IAN., .. F.L.ORI IAA . 3 2 9.7 8........... ............................... .
of the County of ......INDIAN RIVER .................. an:] State of ....... FLORIDA
as Grantee, WITNESSETH:
That the Grantor for and in consideration of the sum of $ , .l.s. 9 : 00............ 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 ......... heirs, legal representatives and assigns
the following property situated in Sebastian, Indian River County, Florida, to -wit:
All of Lot(s) . 7, j 8. , Block, 2 .. , UNIT 4 ........ , of Sebastian municipal cemetery as per Plat Number 1 thereof recorded in Plat
Book 2, at page 6S 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, 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 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.
Attest: ..... ....... ...�/ .....................
CIty Clerk
Signed, Sealed and Delivered
in the Presence of:
V�
�.......... ia4ll�Lay....
STATE OF FLORIDA
COUNTY OF INDIAN RIVER
CITY OF SEBABTIAN, FLORIDA
By . KO,- ?4 ^!l..V1� . �.9 ......... .
Mayor
Wit Jseal)
I HEREBY CERTIFY, That on this ...$.th ................day of .......4U.? �...... ..............................I �.. 0
before me personally appeared .....Walter W. Barnes and Sally A. Maio
respectively Mayor and City 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 conveyance to
.................. ............................... Helyn.. Wo j. tan................................. ...............................
.............................. ......................... and severally acknowledged the execution thereof to be their free act and deed
as such officers thereunto dl.ly authorized; and that the Official seal of said corporation is duly affixed thereto, and the said conveyance
Name
Unit
Block
Lot
Date of Mark-out
Date of Burial Time
Name of Funeral Home
Authorized by
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FLORIDA DEPARTMENT OF
HEALT
(TVPF1
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
�aa
uy
1. Name of First
Middle
Last
Date
Month Day Year
Deceased
of
Jan
William
Wojtan
Death
Aril 2 2002
2. Place of Death City, Town or Location
Name of (If neither, give street address)
County
Hosp. or
Indian River Vero Beach
Inst. VNA Hospice House
3. Name of Medical
Address
Phone Number
Certifier Richard Cunningham, D. O.
2000
38th Avenue
Medical Examiner Physician
Vero
Beach, FL
772 -794 -2227
4. Name of Funeral Home /D�
Address
Fla. Lic. No. /Reg. No.
Phone No. (Area Code)
1623 N. Central Ave.
Establishment
Sebastian,
FL
1228
772- 589 -1000
Strunk Funeral Home
5. Check a. U The medical certification has been completed and slgnea. A completea certiticate OT aeatn accompanies mis
Appropriate application.
Box
b. Glenda was contacted on 413102
He /she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. Cunningham will complete and sign the medical
certification of cause of death within 72 hours. "
C. was contacted on . He /she verified that
Medical Examiner, will complete and sign the
ed cal cepr6catiXof cause of death within 72 hours.
6. Funeral Director/ ign ore .,,/ F.E. No. /Reg. No. Date Signed
0
BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228 -02 -0167
F-�A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician 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.
R Date Date Certificate
Subregistrar Signature M, g�-,RR Issued: 4/2/02 Due: 4/7/02
C. 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. A waiting period of 48 hours after death is
required for all cremations.
D. CEMETERY OR CREMATORY
thod of Disposition: Place of Disposition Sebastian Cemetery
BURIAL STORAGE Date of Disposition ! -Z-/
e /
CREMATION OTHER (Specify)
Signature of Sexton �%
or Person-in-Charge l -el � Q'
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.
Distribution: White: Cemetery or Crematory
DH 326, 8197 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number: 5740- 000. 0326 -2) Pink: Local Registrar