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HomeMy WebLinkAbout4-46-05Name il/f I q/-,L C jGeAe—r / X /a _�s &es Unit Block Lot Date of Mark -out i c Date of Burial ZO/ �S Time • Oa Name of Funeral Ho Authorized by CITY OF SEB�TIAN HOME OF PELICAN ISLAND Certificate No. 2549 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: Regina Marshall 734 Atlantus Terrace Sebastian, FL 32958 In and for consideration of the sum of $1,000.00 is entitled to full interment rights in the Sebastian Municipal Cemetery for the following lot: Unit 4, Block 46, Lot 5 of the Sebastian Municipal Cemetery, as maintained on file in the records of the City Clerk for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. CONVEYED THIS 24th day of October, 2017. CITY OF SEBASTIAN, FLORIDA Joseph F. Griffin City Manager ATTEST: nette Williamis,-A�!C `- City Clerk _ tura SEBASTIAN HOME Of PZM. CAN LStAND City of Sebastian Municipal Cemetery Purchase Receipt To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate regulations, proof of City residency of purchaser or person for whom lot is intended for interment must be provided at time of purchase. Name(s) -T34A4Lan t,�za�� 5�6���rJ FL :3,_ -2 Address __77A 0 Area Code & Phone Number Name & Residence Address of Intended Occupant if Other Than Purchaser OFFICE USE ONLY Receipt is acknowledged in the sum of: (71 l l.S PTlO Dollars ($ I j OCC �) on this day of 20 for the purchase of the following described Cemetery Lot(s) and/or Niche(s). Unit 4— , Block/�- , Lot(s) - Niche( 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 Vase and Ring for Niches (cost) Temporary Marker Preparation & Installation S_,_P_ Ky A(-O'pad CP - Signature of Purchaser I:\W W-DATA\Ms-Cemetery\RECEI PT.doc Interment /w O H Circle One Disinterment TOTAL $ ) i 0C)000 City of Sebastian The following documents were provided as Proof of Residency: FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY For information contact: Kip Kelso, Cemetery Sexton Sebastian Municipal Cemetery Phone: (772) 589-2545 Fax: (772) 228-9927 City Clerk's Office – Cathy Testa City Hall, 1225 Main Street Sebastian, FL 32958 Office (772) 388-8215 or 388-8214 ctesta(d7cityofsebastian.orp 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 CREMAMS LOT OPEN COLUMBARIUM NICHE Lot-5—Block-46–Unit 4 Lot—Block—Unit Niche Block Unit N S E 9- - BURIAL DATE AND SERVICE TIME: Monday 10/30/2017 @ 1:00 PM –Graveside service FOR DECEASED: Margie C. Lockhart Name NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership) Regina Marshall 12Ca�Inci MArshaLL 10/24/2017 Name Signature Date 734 Atlantus Terrace, 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: William B. Whittaker, Jr. Name CWULKB CAttCll2ed, ,JA. Signature 10/24/2017 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. 10/24/2017 14:46 FUNERAL DIREG OR'S REQUEST TO FOR BURIAL OPENING IN SEBASTIAN I For information contat p Kelso, .Cemetery se Phone: (772) 589-254 Fax; (772) 228-9927 cit Clerk's Office -- Cathy ity Hall, 1225 Main Sir, Sebastian, FL 32958 office(772)384-815 or 388-8214 ctesta(i FUNERALI ADDRESS: PHONEM Check One )Q= OPEN BURIAL LOT OPEN CREMAINS LOT OPEN COLUMBARIUM NICHE BURIAL DATE AND SERVICE FOR DECEASED: Margie C. Lockh Name NAME AND SIGNATURE OF LOT OW (Must provide proper documentation of Reqina Marshall Name 734 Atlantus Terrace, sebastiar„ Florida, 32958 1 certify that I have determined the ownr fees have been paid and authorize opei NAME AND SIGNATURE OF LICENSE William B. Whittaker, Jr. Name Cemetery Sexton Certification: I certify that I have checked the ownership i office and that all fees have been paid: This form to be providdd to Clerk's Office l4M Signature OF :00 #7167 P.001/001 p of the above describel lite that all i fees and administrative of same. JNERAL DIRECTOR: %EWA 8 % kittaka, A, Signature )formation by viewing thf owner's c _ b � Date Sexton for permanent r rd upon confirming with Clerk's State of Florida, Department of Health, Bureau of Vital Statistics O�l"`r`I't�a BURIAL TRANSIT PERMIT HEALTH DATE PRINTED: October 24, 2017 TRACKING NUMBER: 2017168228 1. DECEDENT INFORMATION Name of Deceased Date of Death MARGIE C LOCKHART October 23, 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. Lic. 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. Lic. NoJReg. No. WILLIAM B. WHITTAKER F026900 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. O tober 2 , 20-5184 17 ��- Date Issued: October 23, 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 J_�, on CA Llama Method of Disposition: BURIAL Date of Disposltidn: I b "O I DOI� 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 CITY OF SEBASTIAN 10936 ADMINISTRATIVE SERVICES RECEIPT Name L_0CKhA-a_r ❑Cash Date 10 04 f VCheck # 47 g 9 O 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 (.iS I D /U ,:R *3 g60 %7- (O00 (jw r 4 ZIP_Lk:- ,L � °6) 10 Total Pal Initials White - Dept. of Origin • Yellow - Admin. Svcs. • Pink -Applicant CITY OF SEBASTIAN 10937 ADMINISTRATIVE SERVICES RECEIPT Name �anK LA_A z W_?rO Cash Date jo /a41 17 XCheck # 7741-5 ❑ 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 4oning Fees r,c 1501 ,3 390.5 C/C a29,615 t�j rr -f fix 46 LOT S i Cn !` Total Paid Initials White - Dept. of Origin • Yellow - Admin. Svcs. • Pink -Applicant aTr cf SEv HOME OF PELICAN ISLAND CITY OF SEBASTIAN Cemetery Certificate THIS INDENTURE MADE this 10th day of October, 2017, between Ellen Mae Albo, as Grantor whose address is 1621 Peachtree Ave E Woodville Ga 30669 and the City of Sebastian, a municipal corporation existing under the law of the State of Florida of the County of Indian River, State of Florida as Grantee, WITNESSETH: That the Grantor for and in consideration of the sum of $200.00 to be mailed minus a 5% administrative fee, the receipt where of is herewith acknowledged, does by this instrument grant, bargain, sell, release, convey and confirm unto the Grantee their legal representatives and assigns the following property situated in the City of Sebastian, Indian River County, Florida, to wit: All of Lot 5 , Block 46, Unit 4 , of the Sebastian Municipal Cemetery as maintained on file in the records of the City Clerk. To have and hold the same forever; in fee simple. IN WITNESS WHEREOF, the said party of the first part has caused this instrument to be executed in their name and witnessed the day and year first above written. Witness:Af,,.w✓K3�� By: Zg STATE OF Florida COUNTY OF Indian River I HEREBY CERTIFY, that on this 10th day of October, 2017, before me personally appeared Ellen Mae Albo who produced Drivers License as identification; and who executed the foregoing conveyance to the City of Sebastian and severally acknowledged the execution thereof to be her free act and deed as such an individual, duly authorized. Notary Publ CATHERINE E. TESTA Commission # GG 073881 •+pa= Expires February 16, 2021 •''':P,:°5°" Bonded Thm Troy Fain lmraode 90049S7619 Paid by CEMETERY R~eipt NO...5 .~ 7 .......... Dated .... .]./.3 ./. 8.9 ...... : ......... 400. O0 Monument p~ni~d ................ Not paid $ ....... ¢ .................. (Dst& above ~le line for City l~cord oniy) Lots 4 & 5, Blk.46,Un.4 Harvey and/or Ellen Btinker 931 Evernia St. Sebastian, Fi. NO. 1202 32958 , (lli U of e.basIiau Olemelery {]eeh NO. 1202 hetween the City of Sebastian, a municipal corporation existing under the laws of the l~tate of Florida, ns Grantor and ............................. .Ha. rvey an.d../.o..r....E..ll..e..n..B.r..i.,n..k.e.~ .............................................. Florida of the County of ........ Iad£an..R£va.r ................ ~.l State of ........ · ............................................... ~ Oruntee, WITNRS-q~THI ' That the Granto~ fo~ and in cor~dda~aldun of the sum of $ ..... ~01]. ~00. ........... to it in hand paid, the receipt whereof is herewith ac- knowledged, do~s by this ins~rumant ~ant, basalt, sell, release, conwy and confirm unto the Grantee . ~,h~..~ hairs, legal representatives and assigns the following property situated in Sebastian, Indian Rivet County, Florida, to-wit: 4& 5 46 4 A~ of Lot(s) ........ Block, ........ , UNIT .............. of Sebas~iun municipal ceme~y as pe* Pl~t Numb~ 1 the~of recozdcd in Plea Book 2, at page 65 of thc public records in the office of the Clerk of the Ckanir Cour~ of St. Lucie County of Florida; said land now lying and being in Indian P,.iv~ County, Florida. To Have and to Hold the same foreve£; p~ovidad that said property shall be used solely and exclusively for thc mtermunt of the human dead and shell b~ used, kept and maintained at all times in accoldance with the rules and regulatinns, ordinances and resolutions of the City of Sebasti~Ul, Florida. hereto- fore, now and hereafter adopted or provided for the government and operation of said cemetery. Tha conditions, rest£ictions and req-irements contained atte~ed by its City Clerk and its corpoxate seal to be hereto affixed, the day and yea[ fus~ above wrlt ~n. City ~lerk CITY OF SEBASTIAN, FLORIDA Ma,*or Sii~ned, Sealed and Delivered ........ :::.,: :%1. ...................