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HOME OF PELICAN ISLAND
Certificate No. 2640
CITY OF SEBASTIAN
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Leonor Perez
14300 99`h Street
Felismere, FL 32946
In and for consideration of the sum of $2,000.00 is entitled to full interment
rights in the Sebastian Municipal Cemetery for the following lot:
Unit 3, Block 72, Lot 3
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 1st day of July, 2019.
CITY OF SEBASTIAN, FLORIDA
Pa`GI E. arlisle-
City Manager
ATTEST:
Jty
at Williams, MMG Clerk
Lin LT
SEBA,,
HOME OF PELICAN ISLAND
1225 Main Street
Sebastian, FL 32958
(772)589-5330 Phone
July 5, 2019
Mrs. Leonor Perez
14300 99" Street
Fellsmere, FL 32946
RE: Interment Rights to Unit 3, Block 72, Lot 3, in the Sebastian Municipal Cemetery.
Dear Mrs. Perez:
Enclosed is City of Sebastian Certificate 2640 entitling you to full interment rights in
Unit 3, Block 72, Lot 3 in the name of Leonor Perez.
If you have any questions, please contact our office at 388-8209.
S%incerely,
l ,
Cathy a
Recor s Clerk
Enclosure
wr of
$EA TIAN
-
900
HOME OF Peuarl swan
City of Sebastian Municipal Cemetery Purchase Receipt
To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate
regulations, proof of City residency of purchaser or person for whom lot is intended for interment must
be provided at time of purchase.
LEdrJcr, PEREZ
Name(s) FeuS M c—te
l�?,oa q� �r Fi. -3-%94c
Address
3a1 5b7 a2721
Area Code & Phone Number
Name & Residence Address of Intended Occupant if Other Than Purchaser
OFFICE USE ONLY
Receipt is acknowledged in the sum of:
�W0 of Sa p, { rcd Dollars ($ ar�0 00 )
on this day of
Cemetery Lot(s) and/or Niche(s).
Unit 3 , Block ?X , Lot(s) 3
20_ for the purchase of the following described
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 - $20) Opening & Closing 0"(7
Vase and Ring for Niches (cost) Interment
Temporary Marker Preparation & Installation
Sfginatu`re of Purchase
I:\W✓ .DATAWs-Cemetery�RECEIPT.doc
/W O H
Circle One
Disinterment
TOTAL$ ard'5b•(7;0
City of Sebastian
The following documents were provided as Proof of
Residency: I
J �Cwza L °d'450 -and
CITY OF SEBASTIAN 11709
ADMINISTRATIVE SERVICES RECEIPT
Name Yi=
❑ Cash
Date
❑ Check #
`O -Credit
r
Amount Paid
001001 208001 Sales Tax
001001 220000 Security Deposit
001501 362100 Taxable Rent
001501 362150 Non -Taxable Rent
450010 369900 Airport Badge
001001 218010 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
L (.!10 1 C Rel3 700 Lm- `CCG ?�
n-IS'C)3+-1-30,1 C>./C- # a?Z�.90
IJN, 3 - LOT --3
t.
�y�
l Total PYWA5?� Cb
Initials
White - Dept. of Origin • Yellow -Admin. Svcs. • Pink -Applicant
State of Florida, Department of Health, Bureau of Vital Statistics
tf or BURIAL TRANSIT PERMIT
HFMTd DATE PRINTED: July 6, 2019 TRACKING NUMBER: 2019107988
1. DECEDENT INFORMATION
Name of Douasetl Date of Deem
JOSE ROBERTO RENDON June 30, 2019
Place of Death - County City, Town or Location
Name of facility, or shelf address if not a facility
INDIAN RIVER FELLSMERE
191 SOUTH BAY STREET
Name and Address of Funeral HomeflArect Disposal Establishment
Fla. Lic. NOJReg. No. Phone Number
SEAWINDS FUNERAL HOME F073380
F073380 (772)58&1933
735 SOUTH FLEMING STREET
SEBASTIAN. FLORIDA, 32958
Funeral DirectorlDinect Disposer
Fla. Lic. No./Rog. No.
P NICK VAN WAGENEN
F044705
Medical Verification Statement
Paige at me certifying physician's amce, was cathected on 07/0112019 by the
funeral director listed above; relate Indicated that
MICHAEL ANTHONY VENAVO, certifying physician, win complete and sign We medical certification of cause of dram within 72
houn.
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: 2019 l 2019 05147
�- Date Issued: July 1, 2019
State Registrar
3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL -AT -SEA, or HOSPITAL DISPOSITION
Authorinfion given by Medical Examiner District 19 Approval Number:
4. CEMETERY OR CREMATORY
Place of Disposition: SEBASTIAN CITY CEMETERY
Method of Disposition: BURIAL Date of Disposition: 6
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 me copy of the permit for their file they may do so.
OH 328E. 10/12
04V-1 ol1. FbMe Administtaeve Code