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• NO.
THIS INDENTURE MADE This ......1.3t11......... day of .........i!e.Ge 1?�.z ...................... A. D..X16.2QQ0
between the City of Sebastian, a municipal corporation existing under the laws of the State of Florida, as Grantor and
William H. Melton
........................ .............................me ...... .. e...................... ...............................
1541 Emerson Lane
............... ....................Sebas.tian, .. Eloxida ..329 5. 8................. ............................... .
of the County of .......... ..... Indian•,R qer ............... an•] State of ....... Floridi4.... ...............................
as Grantee, WITNESSETHs
That the Grantor for and in consideration of the sum of $ 5.Q Q r O Q , , , , , , , , , , , , , , to it in hand paid, the receipt whereof is herewith so-
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) , A 6, , , , Biock, . 21.. , , , UNrr ....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 iuch 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 sane 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,
Attests ........ .•..•
/-� City Clerk
and
.... �. r
....... .....
CITY OF SEBASTIAN, FLORIDA
By 15
Mayor
Offitv *211)
STATE OF FLORIDA
COUNTY OF INDIAN RIVER yy /
I HEREBY CERTIFY, That on this .......1.7' X4 .......... day of .(OeeP ......... ...................... a •a�c�c�
before me personally appeared ... W81ter • W,. , ,Rarngk'9 ............................ and ..Sally.. A.. Xaa.R..............
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 coaveyance to
William H. Melton
........................................................................................................ ...............................
........................................................ and severally acknowledged the execution thereof to be their free act and deed
as such officers thereunto 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.
WITNESS my sismature and official seal at Aehaatian. in the County of Indian River and gtAtn of Flnrida. the day and vear
d
Name--(,,)
Unit
Block
Lot L-�, --,
Date of Mark -out
Date of Burial `�r
<� Time
Name of Funeral Home Q `�
Authorized by
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FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
SEBAST
NDMf 6i PFIKAN ISL"D
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:
ADDRESS:
PHONE #: 3�! • ray- 2 Z 2y
(Check e)
PEN BURIAL LOT Lot lock Unit
_OPEN CREMAINS LOT Lot Block Unit
_OPEN COLUMBARIUM NICHE Niche Block Unit
W
BURIAL DATE AND SERVICE TIME:
FOR DECEASED: ��,1�.�v1 /�. ate•
Name
NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE:
(Must provide proper documentation of ownership)
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 FUINERAL DIRECTOR
Al
Name 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 Lind that all fees have been paid
.� s<i /
Ceme ry S xton Date
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.
ED En
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STATE OF UTAH DEPARTMENT OF HEALTH
OFFICE OF VITAL RECORDS AND STATISTICS 2011014216
CREMATION / BURIAL - TRANSIT PERMIT STATE FILE NUMBER
THIS PERMIT MUST ACCOMPANY REMAINS TO DESTINATION
REQUIREMENTS FOR CREMATION / BURIAL - TRANSIT PERMITS:
Registrar: This permit may only be issued upon registration of a death certificate and review by the Medical Examiner's
Office when required.
Funeral Director or Mortuary: A Cremation /Burial- Transit Permit is required for dead bodies to be cremated, dead bodies or
fetuses to be transported out of Utah for final disposition, or when disposition is made by someone other than a licensed funeral
director. All cremations must be done by a licensed facility. All permits must be endorsed and recorded.
Dispositioner: A Cremation /Burial- Transit Permit is required for the removal and transport of dead bodies or fetuses from the
place of death and for final disposition.
Sexton: A Sexton or person in charge of any premises where interments are made may not inter or permit the interment of any
dead body or dead fetus unless the interment is made by a licensed funeral director or by a person holding a
Cremation /Burial- Transit Permit.
INFORMATION AS REPORTED ON THE ORIGINAL DEATH CERTIFICATE
1. DECEDENT'S NAME (First, Middle, Last)
2. SEX
3. DATE OF DEATH 13a. COUNTY OF DEATH
William Harrell Melton
I Male
I November 28, 2011 1 Utah
4. DATE OF BIRTH (Month, Day, Year)
5. AGE
6. BIRTHPLACE
November 26, 1928
83
Broughton, Illinois
AUTHORIZATION FROM FAMILY OR INFORMANT
7. NAME OF NEXT OF KIN OR OTHER PERSON AUTHORIZING DISPOSITION (First, Middle, Last)
7a. RELATIONSHIP
Margaret E. Talker
daughter
8. MAILING ADDRESS (City, County, State)
Springville, Utah, Utah
MANNER AND PLACE OF DISPOSAL (FUNERAL DIRECTOR)
10. NAME OF FUNERAL HOME/ DISPOSITIONER
ADDRESS OF FUNERAL HOME OR DISPOSITIONER (City, County, State)
Premier Funeral Services
111.
7043 Commerce Park Drive , Salt Lake City, Utah 84047
12. NAME OF FUNERAL DIRECTOR / DISPOSITIONER (First, Middle, Last)
12a. LICENSE NUMBER
Jared O M Fairbanks
1116412
13. METHOD OF DISPOSITION(S)
(check Applicable Items): 0 Burial in Utah 11 Cremation FRI Transit to outside of Utah [:] Other (Specify)
14. BURIAL DATE IN UTAH OR DATE BODY MOVED OUTSIDE OF UTAH
NAME OF CEMETERY, CREMATORY OR PERSON(S) RECEIVING REMAINS
(Month, Day, Year)
115.
Sebastian City Cemetery
16. ADDRESS OF CEMETERY OR CREMATORY (City, State)
Sebastian, Florida
17. ADDRESS OR OTHER DESCRIPTION SUFFICIENT TO IDENTIFY SCATTERING OF REMAINS
A CERTIFICATE OF DEATH HAS BEEN FILED AS REQUIRED BY THE LAWS OF THE STATE OF UTAH. PERMISSION IS HEREBY
GIVEN TO DISPOSE OF THIS BODY. FOR QUESTIONS REGARDING THIS PERMIT, PLEASE CALL (801) 538 -6371 OR (801) 538 -6364.
This death HAS been reviewed by the Office of the Medical Examiner. Remains ARE authorized for cremation and /or removal from
the state.
This death HAS NOT been reviewed by the Office of the Medical Examiner. Remains ARE NOT authorized for cremation and /or
removal from the state.
UDOH - OVRS -14 Rev. 05/09
December 15, 2000
William H. Melton
1541 Emerson Lane
Sebastian, Florida 32958
Dear Mr. Melton:
Enclosed is Cemetery Deed number 1768 for Lot 36, Block 21, 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. A copy of the receipt is enclosed for your records.
If you wish to have this deed recorded, you may do so at the office of the Clerk of the Circuit
Court, 2000 16th Avenue, Vero Beach, Florida 32960.
Sincerely,
Sally A. Maio, CMC
City Clerk
SAM/js
Enclosures
Ite Sebastian Ceme
City of Sebastian, Florida
Receipt is acknowledged in the sum of:
Dollars ($ ,SdD • 01S )
From:
on this 13a day of /, 20 d, for the purchase of the following
described Cemetery Lot(s)/Niche(s) upon the terms and conditions as stated herein:
Description of Property:
Cemetery Lots) /Nche(s) 31 Block --2/ Unit
Purchase Price: S44.1_ezlx� Dollars .($ 52) 4
Terms and Condition of Sale:
This contract shall be binding upon both parties, the seller and-the purchaser, when approved
by the owner of the .property above described:
1, or we, agree to purchase the above described property on the terms. and conditions stated in
the foregoing instrument
Purchaser signature
Purchaser signature
The City of Sebastian agrees to sell the above mentioned property to the above named
purchaser(s) on the terms and conditions stated in the above instrument.
City of Sebastian
Witness
MELTON, WILLIAM H. DEED 41768
1541 EMERSON LAND
SEBASTIAN, FLORIDA 32958 LOT 36, BLOCK 21,
UNIT 4
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