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HomeMy WebLinkAbout4-41-23Name a,.,c �, A .1 0���11' G,eL�VI.4� W / •C, ��• Unit Block V Lot 12.11% Date of Mark -out 57 IV Date of Burial �/e x ! l6' Time Name of Funeral Home J ` ,O ON Authorized by 05/10/2016 10:18 #5625 P.001/001 FUI IERAL DIRECTOR'S REQUEST TO (11Y FOR 3URIAL OPENING IN SEBASTIAN IIA OF J 4101PA.CE IEBA ST AN VITTERY For information contact Kip Kelso .Cemetery S Sebastian Municlpal Com (772) 589-2545 n t pry l City Clerk's office i City Halls 1225 Main Str � Sebastian, FL 82958 ! Offike (772) 388-8215 or 38 214 Fax: (772) 589-5570 • Str nk Funeral Home and Crematory FUNERAL I-IOi�. i ADDRESS: x.623 North entral Avenue. Sebastian Florida 3295 PHONEM (Check One) XXX _OPEN BURIAL. L T Lot -23 lock i Unit 4 .OPEN CREMAIN LOT Lot Block Uni OPEN COLUMBA RIUM NICHE Niche_E l ck U it T__ lay 12, BURIAL DATE AND SER ACE TIME: 2:00 Pin, Thursday, 20 JO GRAVESIDE SERVICE FOR DECEASED: Pri illa Mae Jordan I ; NAME AND SIGNATURR OF LOT OWNER OR REPRESENTA (Must provide proper do mentation of ownership) Name Signature I certify that I have Beteined the ownership of the above describe ite that I) fees have been paid and uthorize opening of some. NAME AND SIGNATURt OF LICENSED FUNERAL DIRECTOR: Tim Marvin Name Signature Cemetery Sexton Certif tion: I certify that I have checkad the ownership information by viewing th owner otliee and that all fees hai a been paid: Cemdterf Sexton Date This form to be provided tp Clerk's Office by Sexton for permanent r ord ul 519!_ Daae ies and administrative 519/2016 Date confirming with Clerk's CITY OF SEBASTIAN 10086 ADMINISTRATIVE SERVICES RECEIPT Name 6 v tj ❑ Cash Low Date 2 Zo 4 $ Check # 0 Credit Amount Paid 001001 208001 Sales Tax 001001 220000 Security Deposit 001501 362100 Taxable Rent 001501 362150 Non -Taxable Rent 450010 369900 Airport Badge 001001218010 CobraServe 001501 354100 Code Enforcement Fines 001501 347557 Community Center Revenue 001501341920 Copies 001501 351140 Parking Citation 001501 342100 Police Security Services 001501 329200 Site Plan Review 001501 329300 Subdivision/Plat Review 001501 329100 Zoning Fees 0015Z1 1 343 26S ©/c- . Uo Total Paid%k/ �• Initi Is Security Dep Held - Amount $ Check # White - Dept. of Origin • Yellow - Admin. Svcs. • Pink - Applicant PRISCILLA MAE JORDAN November 21, 1929 - May 5, 2016 Mrs. Priscilla Mae Jordan, 86, died May 5, 2016 at Indian River Medical Center in Vero Beach. She was born in Newburyport, Massachusetts and lived in Sebastian since 1986. She enjoyed playing bingo, doing puzzles and mostly being with her family, Survivors include daughters Lynne Griswold of Sebastian and Becky Sema of Sebastian, son David Wayne Jordan and his wife Ginger of Barrington, New Hampshire,, grandsons David James Jordan of Milton, New Hampshire, Mark Griswold of Colorado and Stephen Griswold of Palm Bay, five Great -Grandchildren and sister Barbara Langlois of Merrimac, MA. She was preceded in death by her husband Marvin Jordan in 1990. Memorial contributions may be made to Alzheimers/Parkinsons Association, 2300 5th Avenue Suite 150, Vero Beach, FL 32960. Interment will be in Sebastian Cemetery. Bom: November 21, 1929 Death: May 5, 2016 FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY FUNERAL HOME: 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 Strunk Funeral Home and Crematory ADDRESS: 1623 North Central Avenue, Sebastian, Florida, 32958 PHONE#: 772-589-1000 (Check One) XXX OPEN BURIAL LOT OPEN CREMAINS LOT OPEN COLUMBARIUM NICHE Lot-23—Block 41 Unit 4 Lot—Block—Unit Niche Block Unit N S E W BURIAL DATE AND SERVICE TIME: 2:00 pm, Thursday, May 12, 2016 GRAVESIDE SERVICE FOR DECEASED: Priscilla Mae Jordan Name NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership) Lynne Griswold LVtt11E G1iS4V0fif 5/9/2016 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 DIRECTOR: Tim Marvin Name T" W. MCWVLVV 5/9/2016 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 and that all fees have been paid: Cemetery Sexton Date This form to be provided to Clerk's Office by Sexton for permanent record upon completion. State of Florida, Department of Health, Bureau of Vital Statistics {O BURIAL TRANSIT PERMIT HEALTH DATE PRINTED: May 10, 2016 TRACKING NUMBER: 2016073238 1. DECEDENT INFORMATION Name of Deceased Date of Death PRISCILLA MAE JORDAN May 5, 2016 Place of Death - County City, Town or Location Name of facility, or street address if not a facility INDIAN RIVER VERO BEACH INDIAN RIVER MEDICAL CENTER Name and Address of Funeral Home/Direct Disposal Establishment Fla. Lic. No./Reg. No. Phone Number STRUNK FUNERAL HOME- SEBASTIAN F041870 F041870 (772) 589-1000 1623 N CENTRAL AVE SEBASTIAN, FLORIDA. 32958 Funeral Director/Direct Disposer Fla. Lic. No./Reg. No. TIMOTHY W. MARVIN F022789 2. BURIAL - TRANSIT PERMIT The Florida Department of Health, Bureau of Vital Statistics hereby grants permission to dispose of this body in accordance with Chapter 382, Florida Statutes. Permit Number: Mays,041870-5074 �— Date Issued: May 5, 2018 State Registrar 3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL -AT -SEA, or HOSPITAL DISPOSITION Authorization given by Medical Examiner District 19 Approval Number: 4. CEMETERY OR CREMATORY Place of Disposition: VERO BEACH CREMATORY I IL� Method of Disposition: CREMATION Date of Disposition: EDRS maintains all statutorily required information regarding the death record and related burial transit permit, therefore, returning the permit to the county health department is no longer required. If the Place of Final Disposition wishes to retain the copy of the permit for their file they may do so. DH 326E, 10112 64V-1.011, Florida Administrative Code , Paid b, CEMETERY Receipt No. . . . . . . . . . . . . Dated. . . . ~ !. ? ~ I.~ 9. . . . . . . . . . . . .. " List Price $ .?~~.: 9.9........ Net Paid $ .?9.9... 9.9........ Lot 23 Block 41 Unit 4 NO. Maximum No. Burial Spaces. . . . . . . . . . . . . . . . . 1296 Monument permitted... ................... . Pr i scilla Jordan 1285 George St. Sebastian, Fl.32958 (Data above this line lor City Reeord only) atitll of ~tba.8tian mrmrtrry m rrb NO. "1296 THIS INDENTURE MADE 'I1aII . .~.l ~ ~ . . . . . . day of .... .S.E;!p~~.IJl.b~f......................... A. D.. 19.9.0... between the City of Seboltian, a municipal corporation existing under the laws of the State of Florida, as Grantor and . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . g ~ t.I?<;:.~ 1, ~.? . ~ q rQ..~n . . . . . . . . . . . . . . . . . . . . . . . . 1285 George St. . ... .... ... ....................... Se bast ian,.. Flex ids. . 329.5.8...... . .. ....... .......... '" ........................ . .............. ....................., ...... 01 tbe County 01 . .In.d;i,an. E;i, v.ex...................... anI State of ... Flox.:ida....................................... as Grantee, WITNESSETH I That the Grantor for and in consideration of the sum of $ '" f.9~ : .Q9.. . .... . . . . . . .. to it in hand paid, the receipt whereof is herewith ac- knowledged, does by this instrument grant, bargain, sell, release, 'convey and conium unto the Grantee. . h~.~ .. heirs, legal representatives and assigns the following property situated in Sebastian, Indian River County, Florida, to-wit: All of Lot(s) . . ~~.. ,Block,.. f+. ~. .. ,UNIT ...~......... ,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 propert y shall terminate and the same shall revert to the City of Sebastian, Florida. IN WITNESS WHEREOF, The said party of the lUst 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 aflIXed, the day and year lUst above written. Attest:'K~ .~m .'. .f)/I~!~....... (J . - City Clerk CIT:,07i~~..... ".,r (CllitV JieaJ) TATE OF FLORIDA COl'NTY OF INDIAN RIVER I HEUEDY CERTIFY, That on this ....Z.l.S.t.............day of ..Sep.temb.er.................................. 19..91) bl'fllre me personally appeared ........ ~ :. ..~ .... .9.<?~y~.r.~. . .. .. . . . . . . . . . . .. . . . . . . . .. and ... K~th;r:YI:1.. Q .1.<<l;lJ1,~:r~n... . respr.ctively 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 Indh.jduuls amI officers described In IInd who executcd the fo(('going cORvcyance to ........................ ... ..... ....... ..... ..J;>.t;';i,~.~.~;I,1.l;l.. J~r.<l.~n.............. ......................... .... ..... ....... ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. and severally acknowledgc>d the execution thereof to be tbelr free act and deed as sllch officers thereunto duly authorl.zed; and that the Official sell I of said corporation Is duly affixed thereto. Rnd the said conveyance is thc lIet Ilnd deed of laid corporation. WITNESS my signature and official leal at Sebastian, In the County of Indian River !1m} State of Florida, the day and Jear last aforesaid. (f:y e . ~~~' . . A..-:f 'v. .- _ _ _ ..~ . ..:;.-':::-._.........~........ ..... ..(~~? ................. Notary Public, State 01 Florida at Lar, l. My commission explrelt r::~7"J fr',:'\', !f::;;:l c~ rh::::J r.'r (C!T;~:f':!"',,, ;..~" 'J r~o;I"1\ l'"'1. ..., ,... ....J~. . ,_" '" :J, j a, ih..:;"-..,rJ lluL'lrc,! ruin. k.:ulono.::e hie. Name MA-~Vi ~ l...J :roA,uA ,,; Unit Block L..j \ Lot ~3 Date of Mark-out 7jtflo! 9 () Date of Burial q/ ~ ~I / CPo ::::,:~U:~lHP~~~. ,.-- Time II ~ 30 '1 ~ . .. J~.~ 5~ ----_.-~,,--_. ' - ,.~..._-~ JOIDAN;10 PRISCILLA 1285 George St. ISebastian, Florida 32958 DEED 111296 J' Lot 23 Block 41 Unit 4 :lJ1~4fi./ ~~ y-c/~-?CJ I t/ a;tP ~ ~ '-, Lot 23 Paid by CEMETERY Receipt No..... ?4f........ Dated... 9/21/90 Block 41 ........................... U' t 4 NO List Price $ 200.00. nl' . . . . . . . . . . . . . . . . . . Maxunum No. Burial Spa res. . . . . . . . . . . . . . . . . NetPaid$ .?~9...9.q........ . Monument permitted . . 1296 q~ ~ ~ f'_.?'1';~...................m;c~;~~g~o~~~n (Data above tbla Une for City Reeord only) Sebas tian, Fl. 32958 . . City of Sebastian POST OFFICE BOX 780127 0 SEBASTIAN, FLORIDA 32978 TELEPHONE (407) 589-5330 0 FAX (407) 589-5570 September 24, 1990 Priscilla Jordan 1285 George st. Sebastian, Florida 32958 Dear Mrs. Jordan: Enclosed is Cemetery Deed No. 1296 for Cemetery Lot 23, Block 41, Unit 4. If you wish to have this deed recorded you may do so at the office of the Clerk of the Circuit Court, 2145 14th Avenue, Vero Beach, Florida. Also enclosed is a form - Return for Transfers of Interest in Florida 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. We are enclosing two copies of Receipt No. 642 and ask that you sign and return to us the copy marked with an "X" and retain the other copy for your records. A stamped, self-addressed envelope is provided for your convenience. . Very truly yours, cJ4.-'rJJ OJf/~ Kathryn M. O'Halloran City Clerk KMO: j s enclosure . . ~;; JJ'- . THE SEBASTIAN CEMETERY City of Sebastian Sebastian, Florida FROM: RECEIPT IS HEREBY ACKNOWLEDGED OF THE SUM OF: ~~ /!~J ~) /Jl-YS ~ s/c . ~,F~ - Dollars ($ C:;t1t1. t1'lJ ) Jc:2 9St:?' on this 02/~ day Of#~ 19?~ for the purchase of the following described Cemetery Lot(s) upon the terms and conditions as stated herein: Description of Property: Cemetery Lot(s)# ;2,' Block# ~ I ~ Unit# ~ Dollars($ ~t1t!.thJ ) Purchase price:~~ Terms and' conditions 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. I, or we, agree to purchase the above described property on the terms and conditions stated in the foregoing instrument: ~~~fv~_ 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. ~~.~-/~ ~ity of Sebastian ~~ ,- ~' , , . tness . . -- ~ _I. t...hl .. <fJ..AI "I ~ 41 _ --~--- 1I1 AMI_ A i "\ 0 ~ :Do< ~ . 0-4 ~O t-fd~ ~ lill , ~ih[ I .~ .. { 0 ~ 0 - () 1m- '\ ~ 21 UJ ...C ..D f\. = ~ . e_ OJ F .. Z mZ(!! - > ~ ~~z .. >f;tm 0 i Zf' [J":I . :.- ~ ;D r- 0 1~6 0 [J":I zl: [J":I em m - ... 0 N - ~ .. - o ~ 111 ..D o D:I - ru = . \ ~ "'"' ... CD .fI!. ~ ~ ~ () ~ ~ ;u <.0 o CD il\'1 ,"', ~",,'.,..>:r~:? APPLICATION FOR BURIAL - TRANSIT PERMIT J-. c52 3 /6 ~/ / tI~ [[(I.~] State of Florid.partment of Health and Rehabilitative serlo Vital Statistics A. 1. Name of Deceased (Type or Print) First Middle Last DATE OF DEATH Month Day Year MARVIN E. JORDAN 9/20/90 2. Place of Death County INDIAN RIVER 3. Name of Medical Certifier City, Town or Location VERO BEACH ~ Medical Examiner Name of (If neither, give street address) Hosp. or Inst. INDIAN RIVER MEMORIAL HOSPITAL Address Phone Number MICHAEL ZIMMER, M.D. XX] Physician 2300 5TH. AVE. 4. Name of Funeral Home/ Address Direct Disposer 1623 N. CENTRAL AVE. STRUNK FUNERAL HOME/SEBASTIAN SEBASTIAN, FLORIDA 32958 #1228 407-589-1000 5. Check a 0 The medical certification has been completed and signed. A completed certificate of death accompanies Appro- this application. priate Box VERO BEACH,'FL 32960 567-7111 Fla. lie. No.lReg. No. Phone Number (Area Code) b DiI MAUREEN was contacted on 9/20/90 within 72 hours after death. He/she verified that this death was from natural causes, that there was no accident nor other external cause of death, and that DR. ZIMMER will complete and sign the medical certification of cause of death. c 0 was contacted on . He/she verified that ,Medical Examiner, will complete and sign the 6. Place of SEBASTIAN Final Disposition: CEMETERY 7. Funeral Director/ Direct..Qi~ medical certification. In state cemetery/ SEBASTIAN CEMETF.RY crematory - namt:l/county: INDIAN RIVER COUNTY / l-? Siqnatur.e' <'.. FE. No.foRe~.I>IQ . .'. ~c,,~_ 111672 Removal from state Donation Date Signed 9/20/90 B BURIAL - TRANSIT PERMIT Permission is hereby granted to dispose of this body. o A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted as undue hardship would result from filing within the normal time limit. If the certificate cannot be filed within this extended time limit, a "Funeral Director/Oirect Disposer Report" will be filed with the Local Registrar of the County in which death occurred. o No extension of time for filing the death certificate requested. fileylsh ar Or ~.. ~ Q}..i L f'f) (l /II . _ . n Subregistrar Signature 0 - - ~ Permit No. 1228-90-479 Date Issued: 9/20/90 Date Certificate Due: c. AUTHORIZATION for CREMATION, DISSECTION or BURIAL-AT-SEA Signature , Medical Examiner Date or 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 Methods of Disposition: [XJ BURIAL o CREMATION o STORAGE o OTHER (Specify) Place of Disposition Date of Disposition SEBASTIAN CEMETERY Signature of Sexton ) or Person-in-Charge ) ;{ ~ , ~ 9- / /' ;{. J /4b (7t_ . ,-' This permit 111' i:;t be endorsed by th,. Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton) and returned within 10 d<JYs to the locdl HRS County Public Health Unit in the County where disposition occurred. j. HRS Form 326. Feb 89 (Replacps Oct 87 edition which may be used) (Slack Number 5740-000-0326-2)