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Home My WebLink About4-30-01Name jGF-I/>U ��(• Unit Block 3 D Lot Date of Mark -out Date of Burial l(/ N //7 Time Z' �� • [ g RA6�-5 t 1>'16 Name of Funeral Home Authorized by CITY OF SEBASTIAN 10944 ADMINISTRATIVE SERVICES RECEIPT Name a / / V I C (P d 11? ❑ Cash Date 11-10-1-1 VCheck # 1177 ❑ Credit 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 nn i5c, i -�--e43*os o/c 4tL) Total Paid 7-50.60 Initials White - Dept. of Origin • Yellow - Admin. Svcs. • Pink -Applicant CITY OF SEBASTIAN 10943 ADMINISTRATIVE SERVICES RECEIPT Name 011- V I o� PCLQ C- a Cash Date I 1 _ 10 _ 1 -7 U(Check # if I 7L ❑ Credit 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 to D 10 i O 343s0o Lo # of 01) 4�w Total Paid/666. Initials White - Dept. of Origin • Yellow - Admin. Svcs. • Pink - Applicant My or r HOME OF PELICAN ISLAND 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. VIC.KIE C7: COKprN Name(s) 1516 Ca s t l a K P Lout e I Setas t10 -r, FL 32Y,5 5� Address (77Z) 7 ( 3 aot 1003e Area Code & Phone Number Name & Residence Address of Intended Occupant if Other Than Purchaser OFFICE USE ONLY Receipt is acknowledged in the sum of ?�Ak -O/L6 O0-vLA- '�'Aa =--- -,.� Dollars ($ /0U C1 Co ) on this /0 4,14day of /\J 0 U. —'20 / 7 for the purchase of the following described Cemetery Lot(s) and/or Niche(s). Unit q , Block .3 D , 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 - Vase and Ring for Niches (cost) Temporary Marker Preparation & Instal Signature of Purchaser I: \W W-DATA\Ms-Cemele ry\RE C EI PT. d oc Opening & Closing Interment Z5a.00 W O H Circle One Disinterment TOTAL $ 1250. ° O The following documents were provided as Proof of Residency: SEAWINDS FUNERAL HOME 735 SOUTH FLEMING ST. SEBASTIAN FL. 32958 Phone 772-589-1933 Fax 772-589-1939 Name: Vickie G. Gordon Cemetery: SEBASTIAN CITY Cemetery Service: Saturday, November 11, 2017 @ NOON Crossroads Christian Church, Sebastian, Arrive Cemetery, Approximately 1:20pm Need Open and close GRAVE, Tent and Chairs Container STANDARD LINER Thank You, Kathleen Kauffman ABC Vault Fax 772-466-7506 George with ABC Vault Phone is 772-332-8175 £'d 6£6L 689 ZLL ewoH leaeund spuiMeeS e£O 60Z1 60 ^ON Funeral Olrector's Request to City of Sebastian for Surial Opening in Sebastian Municipal Cemetery Contact Information: Kip Kelso, Cemetery Sexton Sebastian Municipal Cemetery Phone (772) 589-2545 Fax (772) 228-9927 City Cler;' s Office Cathy Testa City Hall, 1225 Main Street Sebastian, FL 32958 Phone (772) 388-8209^ Ciel in(�Ciyo:Tsst29 12i I. or, � hec (J Open Burial Lot Lot! Block Unit Open Cremains Lot Open Columbadum Niche Burial Date and Service Tim Deceased Name and Signature of Lot Owner or Representative. (Must provide proper documentation of ownership) Print Name Lot_ Block_ Unit Niche_ Block_ Unit fCirdel N S E W Signature Date ce`+.e+entij e I certify that I have determined the ownership of the above described site that all site fees and administrative ices have been paid and authorized opening of same. Name and Signature of Licensed F eral Directo 1�.�, / 2-0 1 Print Name Signature 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: Cemetenj Sexton 9a7tlow �- /1Z/ / dern9fery SeAbn el Date This form to be provided to Clerk's Office by Sexton for permanent record upon completion. 1: 2opr, l'd 6£61-699-ZLL ewoH Iejeund spulmeeS a£0:SOL L 60 ^oN State of Florida, Department of Health, Bureau of Vital Statistics - --'- — BURIAL TRANSIT PERMIT HEALTH DATE PRINTED: November 9, 2017 TRACKING NUMBER: 2017176612 1. DECEDENT INFORMATION Name of Deceased Date of Death VICKIE G GORDON November 6, 2017 Place of Death - County City, Town or Location Name of facility, or street address if not a facility INDIAN RIVER SEBASTIAN 1596 EASTLAKE LANE Name and Address of Funeral Home/Direct Disposal Establishment Fla. Lie. No.IReg. No. Phone Number SEAWINDS FUNERAL HOME F073380 F073380 (772) 569-1933 735 SOUTH FLEMING STREET GEGAGTIAN, rLO,RQA, 32958 Funeral Director/Direct Disposer Fla. Lie. No./Reg. No. KATHLEEN KAUFFMAN F047386 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: 20 November 6, 20 7 �— 23 Date Issued: November 6, 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: SEB S N CEMETERY Method of Disposition: BURIAL Date of Disposition: 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