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Hooper, Cynthia INST ~ .9t--;,:I.0B426 APR 25, 1991 4t29PM , ," Co' COLlNl'l FL.A. PINLLLA~ PG 1291 OFF.REC.BK 7552 t_ CEMETERY DEED , THIS INDENTURE made this I ~ day of LQ. , 1991, between the City of Clearwater, Florlda, a municipal orporation as Grantor and Cynthia Hooper, whose mailing address is 6944 Aberfeldy Avenue North, Pinellas Park 33709, of the County of Pinellas, State of Florida, as Grantee: For the interment of Nathaniel Only WITNESSETH: That the said Grantor, for and in consideration of the sum of $200.00, to it in hand paid by the said Grantee, the receipt whereof is hereby acknowledged, has remised released and quit-claimed unto the said Grantee, and her heirs forever, all the right, title and interest, which the said Grantor has in and to the following described parcel of land, lying and being in Pinellas ~ County, State of Florida, to wit: Space B, Lot 46, Block 15, Clearwater Cemetery, \ ~. ~ as recorded in Plat Book 60, Page 30, PubJic Records of Pinellas County, Florida. ~ 'lO This conveyance is subject to the condition that Grantee herein shall not ~'~ a ~ assign or convey said property without the written consent of the Grantor, and 2; ~ co to the further condition that said property shall be used only for cemetery ~ I:..) ~ ~ purposes as human burial sites and is subject to such other rules and regulations tu ~ u: a:.~ the City of Clearwater may adopt pertaining to use of said property. a:. - u. UJ 1:..)01- t; ~ TO HAVE AND TO HOLD the same to the only proper use, benefit, and behoof o a:. of the said Grantee and her heirs and assigns forever. o.~ w -.JI U IN WITNESS WHEREOF, said Grantor has caused these presents to be executed in its name by its Mayor Commissioner, by its City Manager, and to be attested and its corporate seal affixed by the City Clerk on the day and year first above written. Personally appeared before me Rita Garvey, Michael J. Wright, and Cynthial~ E. Goudeau to me we 11 known to be the persons who executed the forego i ng instrument of conveyance in the capacity of Mayor Commissioner, City Manager, and City Clerk respectively, and they severally acknowledged that they executed said instrument in their respective capacity by and on behalf of and as the free ,act and deed of the City of Clearwater, Florida, for the uses and purposes th~rein expressed. 11 RF.s::.~A!ff~, ACCT I~ VI O. Witness-Jny han _~ ro~--l--O-day of ...t, --t~, REe -{a~ FEES MTF PTG PIC DOC ] .\LJ This instrument was prepared by: IIJT M. A. Galbraith, Jr., City Attorney TOTAL '110 City of Clearwater, P. O. Box 4748 ~~earwater, Florida 34618 Approved as City Attorney State of Florida, County of Pinellas: CITY OF CLEARWATER, FLORIDA City Manager , : .~ , ~f: -, ',.:, .'. ":).,~ > .(t'. ;1-, .-\_, I \ \ \ , ~, " ,r. :~r and official seal at Clearwater, Florida this the , 1991. ,</ 'l','n:('" I;':)";'" R Documentary Tax Pd, $ \. \D t $ Intangible Tax Pd. Karlcen F, Do Blaker, Clerk, Plnell1l8 County 11 v ....__ _ Depaty Clork' '-', ~ . , Notarv Public, State of fIOr~,' . MV Commission ExpiresA,pril ~~~}991 ; ,.', iondod Thru Tro)' fain -: In$ura(lc.B, ~~~! . !" ,J,I r~,.A " KARLEEN F. DEBLAKER, CLERK I::;ECOFW VERIFIED BY: ~1 ......... STATE OF FLORIDA DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES VI'fAL STATISTICS APPLICATION FOR BURIAL-TRANSIT PERMIT Middle ~ ysician D The medical certification has been completed and signed, A completed certificate of death accompanies, ~cation, ~0 .. O/f ~~ we< oo"t"..d 00 WI w;th;" 72 hours after death. He/she verified that this~th was from natural causes, that the e no accident nor other external cause of death, and that -.- will complete and sign the medical certification of cause of death, c D was contacted on , He/she verified that , Medical Examiner, will complete and sign the medical certification. ---- 6, Funeral Director~ Direct Disposer Signature . g: 7; LJVu.-o Fla. Lic, No./Reg, No, J"7;/ Date Signed f/rjf/ I Permit No. -:;53- B, BURIAL-TRANSIT PERMIT Permission is hereby granted to dispose of this boay, D 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/Direct Disposer Report" will be filed with the Local Registrar of the Count in which death occurred, D No extension of time or iling the death certific requested, Registrar or Subregistrar Signature Date Issued: 1- ~- r;/ ~~:~ Certificate C, HORIZATION for CREMATION, DISSECTION or BURIAL-AT -SEA Signature or Medical Examiner, , Medical Examiner Date , 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 f Disposition: URIAL D STORAGE D CREMATION D OTHER (Specify) Place of Disposition Date, of Disposition ~7#i1~~ Signature of Sexton ) or Person-in-Charge ) 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. HRS Form 326, Oct 87 (Replaces May 86 edition which may be used) (Stock Number: 5740-000-0326-2) INSTRUCTIONS ON HOW TO C.oMPL~TE THE APPLICATION FOR BURIAL - TRJ\NSIT R,ERMIT FORM Section A. APPLICATION FOR PERMIT 1, Type or print name of deceased and date of death, 2, Indicate place of death: County; City, Town or Location; hospital or institution (if not in hospital or institution, give street address), 3. Indic?te the name and address of the physician or Medical Examiner who you determine is to provide the medical certification of cause of death, 4, Indicate name, address, and telephone number of funeral home or direct disposal establishment. 5,-- . a. Check if a completed death certificate, including the _ completed and signed medical certification of cause of death, accompanies the pink copy of the Application for Burial-Transit Permit to the Local.Registrar of the County in which death occurred. (If the completed certificate cannot be obtained in sufficient time to be filed with the 'pink copy of the Application, check 5b,) b. Provide the name of the person contacted in an effort to obtain the name of the physician who is to complete and sign the medical certification portion of the certificate, and the date he/she was contacted, The person contacted must be either the physician or a responsible person whom you determine can speak for him/her, c. Check to indicate if this is a Medical Examiner case, Give the name of the person contacted who verified that the Medical Examiner will compiete and sign the medical certification of cause of death and the date contact was made, 6, Requires signature of applicant, Florida License/Registration number, and date application signed. Section 8, BURIAL-TRANSIT PERMIT Provide permit number, If it is anticipated thafthe certificate cannot be filed within five days from the date of death, five additional days (exclusive of weekends) may be requested and granted by checking the box provided. If this time frame cannot be met, complete and file a copy of the Funeral Director/Direct Disposer Report with the Local Registrar in the County of death and send a copy to Quality Assurance, Office of Vital Statistics, If no extension of time is requested, check appropriate box, The Registrar or Subregistrar who grants the Burial-Transit Permit will sign and date the Permit Application, If it is not convenient for the Subregistrar to sign, it will be signed by the Local Registrar or his designee, (The signature of the Subregistrar on the Burial-Transit Permit need not be the same as the Subregistrar signature on the death certificate.) Section 382,006, Florida Statutes, requires that a Burial-Transit Permit be obtained prior to disposition or removal from the State and within five days after death, It shall be mailed or delivered to the Local Registrar of the County in which death occurred within 24 hours after issuance. NOTE: It is not necessary to wait until the Funeral Director/Direct Disposer has custody of the actual body to begin the paperwork.) Section C, AUTHORIZATION for CREMATION, DISSECTION or BURIAL -AT-SEA Approval for cremation/dissection or burial-at-sea must be authorized by the Medical Examiner, Space for his approval signature and date are provided, In addition, space is provided for the name of the person obtaining telephone approval from Medical Examiner and the date such approval was obtained. (NOTE: DO NOT HOLD UP FILING THE PINK COPY WHILE AWAITING MEDICAL EXAMINER APPROVAL.) Section 0, CEMETERY OR CREMATORY Requires: Signature of Sexton or person-in..charge (or by the Funeral Director/Direct Disposer when there is no Sexton); appropriate box checked to indicate method of disposition; date of disposition; place of disposition.