HomeMy WebLinkAbout3-39-08aName
Unit 3
Block 3
Lot n A
Date of Mark -out 9— 2- �?— .?-, 5�
Date of Burial & :;?, C)
Name of Furneral Home
Authorized by r7
Funeral Director's Request to City of Sebastian for Burial Opening in
Sebastian Municipal Cemetery
Contact Information:
City Clerk's Office
Cathy Testa
City Hall, 1225 Main Street
Sebastian, FL 32958
Phone (772) 388-8209
ctesta(@,citvofsebastian.org
Funeral Home: I ([)1' pal OCTAry
Address: q,)�5 r�elillh®r Simi, Seba�-Y� on, I�1 a2q%_
Phone:.2 ) � �f
(Check)
_Open Burial Lot
_0 Open Cremains Lot
_F-1 Open Columbarium Niche
Unit Block Lotba
Unit_ Block_ Lot_
Unit_ Block_ Niche
Burial Date and Made__
Service Time: \ 2Gt ?_09_ j @ q I G—
"
Deceased Name: ln((Q, I ade_ MM"J 7
Name and Signature of Lot Owner or Representative:
(Must provide proper documentation of ownershi )
Mrm� SarYtzirrt�r
Print Name Signatur€ Date
Co umbi 5e,�Gi6-4(e1fL
Address Phone Number
I certify that I have determined the ownership of the above -described site that all site fees and
administrative fees have been paid and authorized opening of same.
Name and Signature of Licensed Funeral Director:
Taru S _ _ Date
Print Name Signattue Date
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 Certification:
emeter�
S-
Date
This form is to be provided to Clerk's Office for permanent record upon completion.
Funeral Director's Request to City of Sebastiar for Burial Opening in
Sebastian Municipal Cemetery
Contact Information:
City Clerk's Offrce
Cathy Testa
City Hall, 1225 Main Street
Sebastian, FL 32958
Phone (772) 388-8209
cte sta@ cityofs ebastian. org
Funeral
Address:'13b S lrlernlnr,r Slrre+ ,Sebastr an. fr E2QqatJ
Phone:
(c@k)
n Open Burial Lot
Open Cremains Lot
Open ColumbariumNiche
u*tl Block& utbA
Unit Block Lot
Unit Block Niche
bhq lzs
Date
Burial Date and Service Time:
Deceased Name
Name and Signature of Lot Owner or Representative:
(Must provide proper documentation of
PrintName
)
Phone Number
I certiff that I have determined the ownership of the above-described site that all site fees and
administrative fees have been paid and authorized opening of same.
Name and Signature of Licensetl Funeral I)irector:
(rqil Qfi.4hro
slnlnW slenatur;-C/Date
I certiff that I have checked the ownership informatiou by viewing the owner's deed and
confirming with Clerk's Office and that all fees have been paid:
Cemetery Certilication :
Cemetery Date
This form is to be provided to Clerk's Ofiice for pennanent record upotr completion.
I
t l' ,! ,1,1,'ttri:i'Ll'{itt, i,, 'Iffi t-f
ffiCI?
g{O$48 OF PEUE*N ETAND
4-7yyr LZ
f
r6'l,;'f1t:
eig of Scbastian Munieipal Cemetery Purchase Reeeipt
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
{l\n-arc ?o,*,
Name(s)
Address
o-76<+t" 1on Dlrvl-lda,
Sub,rs T1 zaqsuL
Area Code & Phone Number "7u-t-g5ts
Name & Residence Address of lntended Occupant if Other Than Purchaser
OFFICE USE ONLY
Receipt is acknowledged in the sum of:
6u, [J"narraA4"ot ccl t eo Dollars $5Cc,OO
()
on this t*+n a UJab,-e-rc-ZO Al for the purchase of the following describeday of
Cemetery Lot(s) and/or Niche(s).
Unit 3 , Block , Lot(s B'"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:l\n- P, n
*oofrCorner Markers (set of 4 - $20)_ Opening & C losing /W O H
Vase and Ring for Niches (cost)lnterment
TemporaryMarkerPreparation&lnstallation-
t4 q.)4-.L'
S of Purchaser
Circle One
Disintermen
rorAl $ 5SO, oo '
The following documents were provided as proof of
Residency:
and
I :\\AAIV-DATA\Ms-Cem etery\RECE I PT.doc
City of Sebastian