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Home My WebLink About3-74-05NameJoAss! ?�I IIXE 'SAe5 Unit Block Lot Date of Mark -out Date of Burial Y/A6// ;� Time Name of Funeral Home Authorized by v7AC 5$ \ Sr, CES$ J State of Florida, Department of Health, Bureau of Vital Statistics Tom BURIAL TRANSIT PERMIT HEALTH DATE PRINTED: April 26, 2017 TRACKING NUMBER: 2017069186 1. DECEDENT INFORMATION Name of Deceased Date of Death JOAN F WALLESHAUSER April 26, 2017 Place of Death - County City, Town or Location Name of facility, or street address if not a facility INDIAN RIVER VERO BEACH VNA HOSPICE HOUSE Name and Address of Funeral Home/Direct Disposal Establishment Fla. Lie. 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. Lie. 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: April2 , 20170-5084 �— Date Issued: April 26, 2017 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 FYI d` CLIC' (� Method of Disposition: BURIAL Date of Dispositioh: I 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, 10/12 64V-1.011, Florida Administrative Code Cn Lf SEBAST,I HOME OF PELICAN ISLAND 1225 Main Street Sebastian, FL 32958 (772) 589-5330 Phone (772) 589-5570 Fax April 28, 2017 Mr. Jack Walleshauser 172 Delaware Avneue Sebastian. FL 32958 RE., Interment Rights to Unit 3, Blk 74, Lots 5 & 6, Sebastian Municipal Cemetery. Dear Mr. Walleshauser: Enclosed is City of Sebastian Certificate 2533 entitling you to full interment rights in Unit 3, Blk 74, Lots 5 & 6, in the name of Jack Walleshauser. If you have any questions, please contact our office at 388-8209. Sincerely, Cathy Te t Records Clerk Enclosure SEBASTI� HOME OF PELICAN ISLAND Certificate No. 2533 CITY"0- F SEBASTIAN Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Jack Walleshauser 172 Delaware Avenue Sebastian, FL 32958 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 74, Lots 5 & 6 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 26th day of April, 2017. CITY OF SEBASTIAN, FLORIDA ,/ �/.��, Joseph F. Griffin City Manager ATTEST: Z)6&� G04L' Qt - n 'd Je nette Williams, MN•iC City Clerk 04/26/2017 15:16 State of Fic rida, Department of Hei BURIAL TRANSIT PATE PRINTED: April 2;, 2017 DECE DENT INFOR Name of Daeeased JOAN F WALLESHAUSER Place of Death • County CIN, Town 4 r Location INDIAN RIVER VERO 13EPX H Name and Address of Fyneml HcmaMireet Dlepq Nal Establishment STRUNK FUNERAL HOME' SEBASTIAN F041870 1623 N CENTRAL AVE SEBASTIAN, FLORIDA, 32858 Funeral DImttorlDirect Disposer TIMOTHY W. MARVIN ' BURIAL - TRANSIT The Florida Department of Health, Bur au of vital Statistics hereby grants permission to dispose o this body in accordance State Registrar 3. AUTHORIZATIQN for CREMAT Authorization given by Medical Examiner of Nameof VNA HO, Fla_ Llc i F041870 96720 P.001/001 Statistics 2017069186 Data of Death April 26, 2017 street address if not a fac181y Phone Numbar (772) 580.1000 Fla. LIC. NoJReg. No F022788 r Ipter 382, Frids Statutes. Mit Number: 2017-Fa4167o-s884 Pate Issued:Apd128, 2017 -SEA, or DISPOSITION 4' CEMETERY OR CREMAICRY Place of Disposition: SEBASnAN CEMETERY Method of Dispositiop: BURIAL e of Dlaposhio : l 1 EDRS maintains all statutorily rec uired information regardi the death re cbro and related burial transit permit, therefore, re urning the permit to the co my health d partmant is no longer required. If the Place of Final Disposition DH 326E, 10112 ehes to rotain the ropy of the a ma for theirfile tt)ey;may d0 so. 64VA-011, Honda Administrative Code 04/26/2017 12:11 FUNERAL DIRECTOR'S REQUEST TO C ITY OF FOR BURIAL OPE14ING IN SEBASTIAN F I JNICIPA For information contact Kip Kelso, .Cemetery S ton ebastlan Municipal Ce tery Phone: (772) 589-25 Fax: (772) 228-992 Cj ty Clerk's Office — Cath f Testa City Nall, 1225 Main Sindet Sebastian, FL 3295 Office (772) 388-1215 or 388-8214 ciest.06tvoise FUNERAL HOME: Strunk Funeral . arise and crennatory Sebastian, Florida. 329 ,18 ADDRESS: 1623 North Central Avenue PHONE#: 772-589-1000 (Check One) 2 X OPEN BURIAL LOT Lot_5_Blo 74 Un OPEN CREMAINS LOT Lot_Block Un OPEN COLUM$ARIUM NICHE Niche lock BURIAL DATE AND SERVICE TIME: Friday, 4/28/2017 2:00 PM a) St. FOR DECEASED: NAME AND SIGNATURE OF LOT OWP (Must provide proper documentation of c Jack Walleshauser Name 172 Delaware Avenue, Sebastian, Florida, 32858 1 certify that I have determined the owne fees have been paid and authorize open NAME AND SIGNATURE OF LICENSEI Tim Marvin Name Cemetery Sexton Certification: I certify that I have checked the ownersh office and that all fees have been paid: (/gin _O, �f : l�� r C_,,e . KO Signature p of the above describ site that all of same. JNERAL DIRECTOR: TX #6718 P.001/001 Church 8rrive cemetery3 PM and administrative i information by viewing to owner's *0 and confirming with Clerk's V�IV This form to be provided to Clerk's Office Iby Sexton for permanent kr cord upon FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY Sebastian, FL 32958 Office (772) 388-8215 or 388-8214 ctesta(ftityofsebastian.org FUNERAL HOME: Strunk Funeral Home and Crematory ADDRESS: 1623 North Central Avenue, Sebastian, Florida, 32958 PHONE#: 772-589-1000 (Check One) XXXX OPEN BURIAL LOT OPEN CREMAINS LOT OPEN COLUMBARIUM NICHE Lot-5—Block 74 Unit 3 Lot—Block—Unit Niche Block Unit N S E W BURIAL DATE AND SERVICE TIME: Friday, 4/28/2017 _ 2:00 PM @ St. Sebastian Catholic Church arrive cemetery3 PM FOR DECEASED: Name II2I�(�I6U)Ja -L 0_u) ,n U( �e1pGlSh3-n 32 NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership) Jack Walleshauser lade WaLLeshauser 04/26/2017 Name Signature Date 172 Delaware Avenue, Sebastian, Florida, 32958 1 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 TK MWK Signature 04/26/2017 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. For information contact: Kip Kelso, Cemetery Sexton Sebastian Municipal Cemetery Phone: (772) 589-2545 .. Fax: (772) 228-9927 ti^ City Clerk's Office – Cathy Testa Cif- Hall 1225 Main Street Sebastian, FL 32958 Office (772) 388-8215 or 388-8214 ctesta(ftityofsebastian.org FUNERAL HOME: Strunk Funeral Home and Crematory ADDRESS: 1623 North Central Avenue, Sebastian, Florida, 32958 PHONE#: 772-589-1000 (Check One) XXXX OPEN BURIAL LOT OPEN CREMAINS LOT OPEN COLUMBARIUM NICHE Lot-5—Block 74 Unit 3 Lot—Block—Unit Niche Block Unit N S E W BURIAL DATE AND SERVICE TIME: Friday, 4/28/2017 _ 2:00 PM @ St. Sebastian Catholic Church arrive cemetery3 PM FOR DECEASED: Name II2I�(�I6U)Ja -L 0_u) ,n U( �e1pGlSh3-n 32 NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership) Jack Walleshauser lade WaLLeshauser 04/26/2017 Name Signature Date 172 Delaware Avenue, Sebastian, Florida, 32958 1 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 TK MWK Signature 04/26/2017 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. gra S�T�►N HOME OF PELICAN ISMAND 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. O-11 e.s low Se.12 Name(s) IIA Ave,, � rr . FL 3Ac�5 g Area Code & Phone Number Name & Residence Address Other Than Purchaser OFFICE USE ONLY Receipt is acknowledged the sum of: W00 D'-4NG\A-S1j_Af�d 0d/100 —Dollars ($ )?C66. ) on this day of 20 for the purchase of the following described Cemetery Lots) and/or Niche(s). Unit 3 Block �7+ , Lot(s) 5-)' ie 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 `tC �� O� / W O H Circle One Vase and Ring for Niches (cost) Temporary Marker Preparation & Installation Signature of Purchaser I:kWW-DATA\Ms-Cemetery\RECEI PT.doc Interment Disinterm TOTA $ I sn • O b City of Seba ' The following documents were provided as Proof of Residency: CITY OF SEBASTIAN 10436 ADMINISTRATIVE SERVICES RECEIPT Name ,,11 Ulf 110 I(c' Sf4QI CQCash ` Date Y JAGIf'7 )(Check# ZZtR ❑ 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 n01501 3 3805 DIG Total Pai �•w: In" Is Security Dep Held - Amount $ Check # White - Dept. of Origin • Yellow - Admin. Svcs. • Pink - Applicant CITY OF SEBASTIAN 10435 ADMINISTRATIVE SERVICES RECEIPT Name t0AA1 05 ❑ Cash q Date Li IAne 11-7 VCheck # _QLS ❑ 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 (,01(!) 10 Z438�0 LL Sfb 43Q T/ Total Pai 060-- aD Inti Security Dep Held - Amount $ Check # White - Dept. of Origin • Yellow - Admin. Svcs. • Pink - Applicant