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HomeMy WebLinkAbout3-76-04Name 64 14 ; woe Unit ;1 Block�O Lot Date of Mark -out Date of Burial / /T //� Time ;?- �a0 Name of Funeral Home Authorized by s r r Certificate No. 2509 CPT)(SEBASTIAN Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Steven Lulich 1069 Main Street Sebastian, FL 32958 In and for consideration of the sum of $6,000.00 is entitled to full interment rights in the Sebastian Municipal Cemetery for the following lots: Unit 3, Block 76, Lots 3, 4, 5 of the Sebastian Municipal Cemetery, as maintained on file in the records of the City Clerk for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. CONVEYED THIS 6th day of July, 2016. CITY OF SEBASTIAN, FLORIDA Joseph F. Griffin City Manager ATTEST: anette Wi lianps, �Wl City Clerk • .moi i i E 07/06/2016 13:30 FOR FUNERAL HOME: 51 ADDRESS' 1623 Nort PHONE#: .772-5119.1 (Check One) xxxxx OPEN BURIAL OPEN CREMAI OPEN COLUMI BURIAL DATE AND FOR DECEASED: NAME AND SIGNAT (Must provide proper Name I certify that I have fees have been pa NAME AND SIGN) Gary D. Evans Name Cemetery Sexton Cert I certify that I have the office and that all fees DIRECTOR'S REQUEST TO . OPENING IN SEBASTIAN I For information contac Kip Kelso Cemetery Se: Sebastian Municipal Cem (772) 589-2545 City Cleric's Office City Hall, 1225 Main Sh Sebastian, FL 32958 Office (772) 388-8215 or 38 Fax. (772) 589-5570 Funeral Home and Crematory - LOT :IUM NICHE TIME: SATURDAY, 7/9/2016, DelRosso TY OF SI NICIPAL PM St. Lu OF LOT OWNER OR REPRESENTATI imentation of ownership) teven Lurch Signature lined the ownership of the above describsite that all authorize opening of same. OF LICENSED FUNERAL DIRECTOR: Signature the ownership information by viewing been paid: -_), , -7/ cemdteWexton I/ Date ' - This form to be provided �o Clerk's Office by Sexton for permanent 4ord upon #5772 P.001/001 Catholic Church 7/6/2016 Date and administrative 7/6/2016 Date confirming with Clerk's State of Florida, Department of Health, Bureau of Vital Statistics r BURIAL TRANSIT PERMIT 14EIkLTH DATE PRINTED: July 7, 2016 TRACKING NUMBER: 2016106022 1. DECEDENT INFORMATION Name of Deceased Date of Death ROSINA ELENA DELROSSO LULICH July 6, 2016 Place of Death - County City, Town or Location Name of facility, or street address if not a facility INDIAN RIVER SEBASTIAN 8610 RIVERSIDE DRIVE #103 Name and Address of Funeral Home/Direct Disposal Establishment Fla. Lic. NoJReg. No. Phone Number STRUNK FUNERAL HOME- SEBASTIAN F041870 F041870 (772) 588-1000 1623 N CENTRAL AVE SEBASTIAN, FLORIDA, 32858 Funeral Director/Direct Disposer Fla. Lic. NoJReg. No. GARY D. EVANS F066074 2. BURIAL - TRANSIT PERJAIT 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: 2016-FO41870-5111 Date Issued: July 6, 2016 State Registrar 3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL -AT -SEA, or HOSPITAL DISPOSITION Authorization given by Medical Examiner District Approval Number: 4. CEMETERY OR CREMATORY Place of Disposition: SEBASTIAN CEMETERY S "!"" L f )q Method of Disposition: BURIAL Date of Disposition: Il (�v 1 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-1.01 1, Florida Administrative Code CITY OF SEBASTIAN 10104 ADMINISTRATIVE SERVICES RECEIPT Name TRv1`4 I LUU64 ❑ Cash Date 9 (ao Check # "A7q T 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 0015 i 343 205 cc, cc Llt,j IT : Z K q(6 LO -r4 '�" � Total Pa I �is . Security Dep Held - Amount $ Check # White - Dept. of Origin • Yellow - Admin. Svcs. • Pink - Applicant CRYOF HOME OF PELICAN ISLAND 1225 Main Street Sebastian, FL 32958 (772)589-5330 Phone (772)589-5570 Fax July 7, 2016 Steven Lulich 1069 Main Street Sebastian, FL 32958 RF: Interment Rights to Unit 3, Block 76, Lots 3, 4, 5, Sebastian Municipal Cemetery Dear Mr. Lulich, Enclosed is City of Sebastian Certificate 2509 entitling you to full interment rights in Unit 3, Block 76, Lots 3, 41 5, in the name of Steven Lulich. If you have any questions, please contact our office at 388-8209. Sincerely, Cathy Te Records Clerk Enclosure 9 City of Sebastian Municipal Cemetery Purchase Receipt To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate regulations, proof of City residency of purchaser or person for whom lot is intended for interment must be provided at time of purchase. Name(s) ,S ou L %.k Address 9 Area Code & Phone Number Name & Residence Address of Intended Occupant if Other Than Purchaser OFFICE USE ONLY Receipt is acknowledged in the sum of: l S,4-r�1� C o�1 Dollars( $ 6)10 00 } on this 6 "-� day of , 20 for the purchase of the following described Cemetery Lot(s) and/or Niche(s). Unit 3 , Block r76 , Lot(s)3-4-S'- Niche(s) for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. Additional Fees paid at time of purchase: Corner Markers (set of 4 - $20) Opening & Closing Vase and Ring for Niches (cost) Temporary Marker Preparation & Installation Signature of Purchaser I :1W W-DATAWs-Cem eterylRECE I PT.doc Interment /W O H Circle One Disinterment TOTAL $ City of Sebastian The following documents were provided as Proof of Residency: and CITY OF SEBASTIAN 10102 ADMINISTRATIVE SERVICES RECEIPT Name L—.l' " D Cash Date 7 KCheck #� 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 (4 a 1 © I(_) s- 343 Soo aov . °O Uarr AtX Ns LM - 4_0*0 (eo 00. d� Qq Total Paid 160 Security Dep Held - Amount $ Check # White - Dept. of Origin • Yellow - Admin. Svcs. - Pink - Applicant