HomeMy WebLinkAbout3-60-051 Vtl
Name GWe.ndo 1\1 rk ASon 3tias
Unit
Blo^�V O
Date of Mark -out
Date of Burial _ — Time �a-fie
Name of Funeral Home 5'Tan � I: COTIA.15
Authorized by
Cm CF
HOME OF PELICAN ISLAND
Certificate No. 2727
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:
Gwendolyn Johnson
1373 Barber Street
Sebastian, FL 32958
In and for consideration of the sum of $1,000.00 is entitled to full interment
rights in the Sebastian Municipal Cemetery for the following lot:
Unit 3, Block 60, Lot 5
of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and
regulations prescribed therefore by the City of Sebastian.
CONVEYED THIS 8th day of January, 2021.
CITY OF SEBASTIAN, FLORIDA ATTEST:
Paul E. Carlisle Janette Williams, MMG—
City Manager City Clerk = _ --
ML.
SE�T�A1V
HOME OF PELICAN ISLAND
1225 Main Street
Sebastian, FL 32958
(772) 589-5330 Phone
(772)589-5570 Fax
January 13, 2021
Mrs. Janecia Johnson
1373 Barber Street
Sebastian, FL 32958
RE. Interment Rights to Unit 3, Block 60, Lot 5 in the Sebastian Municipal Cemetery.
Dear Mrs. Johnson:
Enclosed is City of Sebastian Certificate 2727 entitling you to full interment rights in
Unit 3, Block 60, Lot 5 in the name Gwendolyn Johnson.
If you have any questions, please contact our office at 388-8209,
Sincerely,
Cathy Tes
Records Specialist
Enclosure
Mfg
SEB"LMN
a7AI
HOME Of PUICAN HAND
City of Sebastian Municipal Cemetery Purchase Receipt
To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate
regulations, proof of City residency of purchaser and person for whom lot is intended for interment
must be provided at time of purchase.
t_--1I_
t(,Ir&1�EI-WJ VGflnlSonl
Name(s) /
Address
Area Code & Phone Number
Name & Residence Address of Intended Occupant if Other Than Purchaser
OFFICE USE ONLY
Receipt is acknowledged in the sum of.,
nA(t-- I'V4161LSA-rJ6 /4-n) O(D//00 Dollars($ i 000. c.o )
1•
on this 9 W-" day of 1 Al""V 20•Rl for the purchase of the following described
Cemetery Lot(s) and/or Niche(s).
Unit 3 Block 60 , Lot(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 'rlI W O H
Circle One
Vase and Ring for Niches (cost) Interment Disinterment
Temporary Marker Preparation & Installation
Signature of Purchaser
I:\W W-DATA\Ms-Cemetery\RECEIPT.doc
OTA $
City of Seb7sti
i_
The following documents were provided as Proof of
Residency:
JCC W-CG
-�FC u,R-t �"/�-
State of Florida, Department of Health, Bureau of Vital Statistics
OriCria BURIAL TRANSIT PERMIT
HEALTH DATE PRINTED: January 9, 2021 TRACKING NUMBER: 2020249070
7. DECEDENT INFORMATION
Name of Deceased Date of Death
GWENDELYN DANE JOHNSON December 31, 2020
Place of past -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 HomelDirect Disposal Establishment
Fla. Lit. Noumea. No. Phone Number
STONE BROTHERS FUNERAL HOME INC- FORT PIERCE F116115
F116115 (772)461-1800
317 NORTH 7TH ST
FORT PIERCE. FLORIDA, 34950
Funeral DirectorlDirect Disposer
Fla. Lie. NOJRag. No.
MARK) BROWN
F081208
Medical Verification Statement
Linda at the certifying physician's office, was contacted on 0IM512021 by the
funeral director listed above: befalls indlwted that
MICHAEL ANTHONY VENAZIO, certifying physician, will complete and sign the medical cenlflcation of cause of death within 72
boom.
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. 2021-1`January 5.2021004
�— Data Issued: January 5. 2021
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
Mece thod of Disposition;
SEBASBURIAL NN CEMETERY f
Method of Disposition: BURIAL Date of Disposition: l% / /�/
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 line 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, Honda AEminisumve Code
CITY OF SEBASTIAN 12582
ADMINISTRATIVE SERVICES RECEIPT
Name:+c"iJ,r, e,z ', j Gt/JSo %,,Cash
Date �' I �O.>i I ❑ Check # Y
Credit
Amount Paid
001501 362150 Non -Taxable Rent
001001 220000 Security Deposit
001501 362100 Taxable Rent
001001 208001 Sales Tax
450010 369900 Airport Badge
001001 218010 CobraServe
001501 354100 Code Enforcement Fines
001501 347557 Community Center Revenue
001501341920 Copies
001501 351140 Packing Citation
001501 342100 Police Security Services
001501220030 PDSHOP
001501366602 PD SAFE
001501 366603 PD COPE
Ioof0lc 343800 Lur 41,coo 60
00ISDI 343805 0IG `ff a'Sy.°o
(IAuE 3 AIKK(,6 L&7' S— pN
,z 3 kJ Total PAid 1 a SD' 46
InNials
While - Dept. at Origin • Yellow-Admin. Svcs.. Pink - Applicant
M�
S BASTLAN
HOME OF PELICAN ISLAND
Sebastian Cemetery
Ph# 772-589-2545
Fax# 772-228-9927
Site Plan for Marker Installation
Funeral Home:
Type & Size of Marker: ')•d X 7•d X0.16
Name
(aw e.t r�aly„
His
Hers �301NAJIA
DOB:
DOB: a 17 / 5 7
DOD:
DOD: 17 / 3/ 120
Unit:
Unit: 3
Block:
Block: to 0
5
Lot:
Lot:
Size Foundation Material
P x 2............................................. Dry mix, consisting of a bag
of concrete (only) includes flat grass marker.
Larger than P x 2................................Formed and poured concrete including base.
Approvedby: See v Date 3 d7 .�d
Marked out by: o < V Date Wanal .71
Foundation Poured by: N e.. " Date 3/07/ 91
Foundation Material 13 cic Date 3/d7 d