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1'HIS INDENTURE MADE T6L ........1,ZC1'1 . dey or .............. Janua.�y.................. e. D., f42.0.Q4
betNeen ll�e City of Sebaetlen, a municipal corporatlon e:iating under the lawe ot the 8tate of Florfde, ne Grantor and
;,J,i1.•A,W?, Scott Gates
... ............................ ................................................................
702' S.i+i.��Barjoer��Street
.... ....... ............................ �e.bas t,i.an.,...FI... 3�2.9.58........ ......... . . . .. . . . ... . .... ........................... .
or �n� County or Indian River Florida
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .� � s�ac� or . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
u GranteG K'ITNES9ETH�
1���•�� ,, to it ' and a�d, the recei t whereof is herewlth ac-
That the Grantor for and in consideraUon of the sum of S..� .. .. .. ........ ... ... . �P � P� P
knowledged, does by this inatrument grant, bargaln, seU, release, convey and confirm unto the Grantee , n, s... heirs, legal repiesentatives and assigns
the following property aituated ln Sebasdan, Indlan Rlver County, Florlda, to-wit:
All of Lot(s)? & 8. .., Block, ,,,19 .. . UNIT ,, 4. .. ....... , of Sebastian munidpal cemetery as per Plat Number 1 thereof recorded in Plat
Book 2, at page 65 of the public records ln the office of the Clerk of the Circuit Court of St. Lucie County of Ftorida; said land now lying and being
in Indlan River County, Flodda.
To Have and to Hold the same fomver; provided that said property shall be used solely and exclusively tor the inte:ment of tha human dead and shall
be used, kept and maintalned at all timea in eccordance wlth the rules and regulatlona, ordinancea and rewlutions ot the City of Sebastian, Floridn, hereto-
[ors, now snd henaftst adopted or peovldsd fot th� aorernment u�d op�r�elon of rdd cemetery. The condltlane, re�teictions and tequiremenn contalned
in thi� irotrument thsll be oov�nant� runnfn� with the Lnd. In the event of the fdlun of the ownsr of any propecty �ituated within uld cemet�ty to ob-
serve and comply wlth such rules, tegulatlona, resolutlona and ordlnanaa snd the condltlons of the dCed oC conveyance thereof then the tltle of such owner
in and to said ptoperty shall terminate and the same shall revett to the City of Sebastlan, Florida.
IN WITNESS WHEREOF, The aald patty of the fltat part has cauaed this lnstrument to be executed in its name and on its behalf by its Mayor and
atterted by its City Clerk and its corporate aeal to be hereto aff3xed, the day and year first above written.
���'�'�.f�'h���-�,,.. . . . . . . . . . .
� city ci���
fed und Dcl(v red
�nce of�
.5�._�.... .... . ................
CITY OF SEISABTIAN, FLOAIDA
H� . . (.���1�,(-a.w�r . . . . . . . . . . . . . .
M:,o� �
((llitg �¢xl)
STA'CE OF FT.ORIAA
CUUNTY OF INDIAN RIVER
I tIE1tEIIY CERTIFY, Thst on thts ........12t�1.........dsy �t ......... JanuarY .............................., 13�!r.Q,��
Chuck Neuberger Kathryn M. 0 Halloran
brture mc pereonally appesred ..................... ... ... ... ..... .
.�a ....................... �...............
respcetively Mayor and City Clerk ot the City at 9ebastien, a tnunicipal corporat(un under the lews of the State ot Florlde to me known
to be tl�e Iudlviduule und ufticers deccrllxd ln und who executcd the turrguing coaveyunce to
Scott Gates ............................................
............................................................................
. and severully scknowledged thc executlon thereot to be their tree act and deed
es such officers theremdu duly authoriscd; and thet the Officisl seul of seld wrporatiun la duly effi � to, and the said conveyunce
�� •ti,, u�i ���d dred ot seid corvoretlon. �
WITNESS my eignature and otficlsl sesl st 8ebaetisn, in the
lest aturrasid. �-1
UNDA M. (iALLEY
MY COMMISSION If CC 740478
EXPIRES: Juie 18, 2002
eaMee tnn� Nohry Pueic undn+l.n
My
Stete t Florj,da, the dey end �esr
� 4 '„ti„`,! . ...... ................�.
Florlda at I.stge.
_....--
Name %� l�/ �[—,� . % !.0 Gr �=i /,�� .
Unit_
Block
l�
Lot �
Date of Mark-out 1` ,/� J
Date of Burial �,���,� � t� Time // ' � 7 /� . �Y7 .
���
Name of Funera Home ��' �� -
��-._.._'�` ! .�-, %
_ � �.-� ----�'�..�� i�, .
—1
,�.
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Paid by CEMETERY Receipt No . . . . . . . . . . . . . . . . . Dated . . . . . .1. � 11 � OO. . . . . . . . . .
List Price $ �. s � Q Q r Q � . . . . . Maximum No. Burial Spa s . . . . . . . . . . . . . . . . .
Net Paid S 1.� 000 : 00 .. ... Monument pernutted . .,.t:' . . .. ... ... .. . .. ... .
�
(Data above t�his line' tor City Record only)
�I��
,V
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NO.
r•���.: !
,� LURIDA DEPARTMENT OF
HEALT '
A. (TYPE)
1. Name of
Deceased
2. Place of Death
County
I ndian River
St f Florida, Department of Health, Vital tics
�LICATION FOR BURIAL_ - TRANSIT PE IT
First - Middle
Ann
City, Town or Location
Roseland
Last
Fugat
- Date
of
e Death
��
� %�
�y
Month Day Year
Jame of (If neither, give street address)
iosp. or
nst. Sebastian River Medical Center
o. rvame or nneaicai acitlress Phone Number
Certifier Frederick Hobin 2500 S. 35th Street
Medical Examiner Physician Fort Pler'C2, FI 561-464-7378
4. Name of Funeral Home/Dir�k�.licpccel Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment 1623 N. Central Ave.
Strunk Funeral Home Sebastian, FI 1228 561-589-1000
5. Check a. � The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
6. Funeral Director/
Direct Disposer
a.
�
b. � was contacted on
He/she verified that 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 within 72 hours.
�• � Helen was contacted on 1/ 6/ 00 He/she verified that
Dr. Hobi , Medical Examiner, will complete and sign the
me I certi tion of u death within 72 hours. '
,/ ' ture F.E. No./Reg. No. Date Signed
.( / 1862 1/6/00
BURIAL - TRANSIT PERMIT
Permission is hereby granted.to dispose of this body. Permit No. 122$-00-001 1
� 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.
i�egietrarbr Date Date Certifi ate
Subregistrar Signature µ Issued: 1 DO Due: ! 1 2 Q!'f
Approval Number:
AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA
Date
Medical Examiner, , gave authorization by telephone to
Funeral DirectodDirect 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.
o. CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition Sebastian Cemetery
�BURIAL �STORAGE Date of Disposition �"��� • ���
�CREMATION
Signat�re of Sexton
or Pereeri-i�r6�yr�,
�OTHER (Specify)
� �_.�l1-_� .
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.
Distnbution�. White: Cemetery or Crematory
DH 326, 8/97 (Obsoleles all prevwus editions) Yellow�. Funeral Oirector or Direct Disposer
iStock Number 5740-000-0326-2) Pink Local Registrer � �