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Home My WebLink About4-21-11Name Unit_ Block Lot ZI Date of Mark -out A14 Date of Burial �� ✓ _Time l VO Name of Funeral Home Authorized by CITY OF SEBASTIAN CITY CLERK'S OFFICE 4799 RECEIPT Name / .5'i ck(and ❑ Cash /� Date) �) I [ Check# 2Cq 2- No. Amount Paid 001001 208001 Sales Tax 001501 322900 Garage Sales 001501341920 Copies /Bid Specs. 001501 341910 LDCICode of Ordinances 001501 341930 Election Qualifying Fees 601010 343800 Cemetery Lots Lot/Niche , Block , Unit 001501 343805 Cemetery Fees 0 ic, , 1 1, Total Paid 50. Initials White - Dept. of Origin • Yellow - Finance • Pink - Applicant JTATEMENT DATE TERMS TO �_ r ADDRESS IN ACCOUNT WITH s r ce fir( 6 _y _z " 6T� ,PXN Oa �- ff s&m DC5812 FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY SEB�T� HOME 01 Pf IIC AN ISLAND 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) 569 -5570 FUNERAL HOME: TAIV7 ADDRESS: PHONE #: (Che One) PEN BURIAL LOT —,_,OPEN CREMAINS LOT ---OPEN COLUMBARIUM NICHE BURIAL DATE AND SERVICE TIME Lot _ />/ Block f _Unit Lot _ ~Block Unit Niche Block Unit ; e., � w FOR DECEASED.,�,�f ivame NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE' (Must provide proper documentation of ownershi 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 DIREG -TOR. Name Signature Date Cemetery Sexton Certification: I certify that I have checked the ownership infonnation by viewing the owner's deed and Confirming with Clerk's office alnd that all fees have been paid /.0 ,�. - t / / Ly xton' Dale Cem tery �/ This forni to be provided to Clerk's Office by Sexton, for permanent record upon completion, Ttfu of Orhastiatt r ut r t r r r f NO. THIS INDENTURE MADE This .........l tll........ day of ...:.... p .� � ............................. A. D.,�1� ..24A1 between the City of Sebastian, a municipal corporation existing under the laws of the State of Florida, as Grantor and ........................................... ....................................... ............................... 2205 E. Lakeview Drive ............ ............................... Sebaa•tian•, . • Flo•r• ida• .329.58 .... ............................................. of the County of .. Indian „fit ver .................... and State of ....... Florida .................................... as Grantee, WITNESSETHt That the Grantor for and in consideration of the sum of $ . 1 Q QQ -.0 Q ............ 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) L !A 12, Block, ... 21.. , 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 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: STATE OF FLORIDA COUNTY OF INDIAN RIVER CITY OF SEBASTIAN, FLORIDA By W. IS &1 vr . .............. Mayor (Cig ,real) I HEREBY CERTIFY, That on this .......11th ..........day of .....Ap.ril ...................................... mL - 2001 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 George Shaul .................................... . ............................................................... :.................................. ......................... ............................... and severally acknowledged the execution thereof to be their free act and deed as such officers thereunto duly authorized; and that the and seal of said corporation is duly affixed thereto, and the said conveyance is the act and deed of said corporation. Name A 0 Unit Block Lot /I Date of Mark - out Date of Burial % Time -t-"A r: Name of Funeral Home Authorized by ry SHAUL, GEORGE DEED 41787 2205 E. LAKEVIEW DRIVE SEBASTIAN, FLORIDA 32958 LOTS 11 & 12, block 21, UNIT 4 DONNA B. SHAUL INTERRED LOT 11 4/12/01 04/05/2016 09:52 Hua 24 8011 i0k 33RM HP LASERJET FAX city of Set}ov ' rn NA8111s1, t 041101 . Pb. IV It l71, SP 154 1'1% I IM 12 Is . 1092 Y�ie : Tltl�i tn► IPA1fMIWh,- ;kI purpowt% rquilcdihX hlupudlrgt, titilst,l,:t `III{, 'I'ilit i tlr 111414 Markm umlor Z it. Ar c++'tr 3 IQ givrr t h,1% I uryt.1 In4i ntvbf IVIW'D1 5900401. .4rd��cl�n t'�alete►L I�t1 !�aTll1 �1►AIIiI �►�i, 11� 3ZySR Alltel N* 1 t'rdlrlrt�ti y'r><IA� 1 +— T sh name 6.0'010: NjGwynt, I, ,• a. a. o. o. U. ,. L&gill DeseflplfT.:: Va .�..._.. Apptovod By chfowsy • '•1�11'1'f: ie �•" 11 STRUNK FUNERAL. HOME & CRS 1623 No. Central Ave. SEBASTIAN, FL 32958 (772) 589-1000 V v na.� j;e11R #5469 P.001/001 c ! Dry MI. vVuutjUPs'11 Iiuurc':! E3y date '•I�,II/' �N�I:IIt�1i !SO00/�. o„T FLORIDA DEPARTMENT OF 1 -SALT A. (TYPE) State of Florida, Department of Health, Vital Statistics All APPLICATION FOR BURIAL - TRANSIT PERMIT 1. Name of First Middle Last Date Month Day Year Deceased of Donna B. Shaul Death April 8 2001 2. Place of Death City, Town or Location Name of (If neither, give street address) County Hosp. or Indian River Roseland Inst. Sebastian River Medical Center 3. Name of Medical Address Phone Number Certifier Ralph B. Geiger, M.D. 13840 U.S. #1 Medical Examiner M Physician Sebastian, FL 561- 388 -0770 4. Name of Funeral Home /Direct Disposal Address Fla. Lic. No. /Reg. No. Phone No. (Area Code) Establishment 1623 N.Central Avenue Strunk Funeral Home Sebastian, FL 1228 561 -589 -1000 5. Check Appropriate Box 6. Funeral Director/ B. a. LJ The medical certification has been completed and signed. A completed certificate of death accompanies this application. b• M La mora was contacted on 4/9/01 He /she verified that this death was from natural causes, that there was no accident nor other external cause of death, and that Dr. Geiger will complete and sign the medical certification of cause of death within 72 hours. C. was contacted on of death within 72 hours. F.E. No. /Reg. No. 1862 BURIAL - TRANSIT PERMIT He /she verified that Medical Examiner, will complete and sign the Date Signed Permission is hereby granted to dispose of this body. Permit No. 1228-01 -0179 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. nNo extension of time for filing the death certificate has been requested. RE"trar or 'i - _ e ' Date Date Certif ate Subregistrar Signature �^ M < Issued: �{` t n Due: 4 O 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 Method of Disposition: Place of Disposition Sebastian Cemetery BURIAL FISTORAGE Date of Disposition ZZ CREMATION OTHER (Specify) Signature of Sexton 1 or Person -in- Charge J} t 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: While: Cemetery or Crematory I DH 326, 8/97 (Obsoietes all previous editions) Yellow: Funeral Director or Direct Disposer ll (Stock Number: 5740 - 000 - 0326 -2) Pink: Local Registrar