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HomeMy WebLinkAbout4-40-35SL'_ !IAN HOME OF PELICAN ISLAND CIT OF S AST1AN Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Josephine M. Kopecky 9650 Estuary Way, No. 1, Sebastian, Fl 32958 (name) (address) in and for consideration of the sum of $700.00 has purchased and is entitled to full interment rights in the Sebastian Municipal Cemetery for the following plot: Unit 4 Block 40 Lot 35 of the Sebastian Municipal Cemetery, as maintained on fde 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 December, 2004. C 0F SEBAST FLORIDA errence R City Manager ore Certificate No. 1994 Sall A. Maio, CMC City Clerk Name oSG Unit Block t> Lot .3`S Date of Mark -out Date of Burial A7/ Name of Funeral Home Authorized by fC1 "i x l c) Time d.:90/1 C 3 0 co i 3 O CO 0 0. z 0 0 s 34 OD w JOSEPHINE M. "JO" KOPECKY (March 4, 1914 February 15, 2011) Ms. Josephine M. "Jo" Kopecky, 96, died February 15, 2011 at her residence in Sebastian. She was born in Elizabeth, New Jersey and lived in Sebastian for 23 years coming from Bellerose, New York. She was employed as an Administrative Assistant with West Point Pepperell, Inc., a company that remains a preeminent manufacturer of sheets, towels, and apparel, for 21 years. She was a member of St. Sebastian Catholic Church. Survivors include her sisters, Jean Beudert and Pauline Camporeale both of Sebastian and numerous nieces and nephews. She was preceded in death by her brother, Arthur Kopecky. FUNERAL HOME: ADDRESS: PHONE FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY SEBASTIA N 74 /cs HOW a ►tLKU+ISLAND For information contact: Kip Kelso Cemetery Sexton Sebastian Municipal Cemetery (772) 589 -2545 City Clerk's Office City Hall, 1225 Main Street Sebastian, FL 32958 Office (772) 388 -8215 or 388 -8214 Fax: (772) 589 -5570 (Check One) OPEN BURIAL LOT Lot Block y Unit __OPEN CREMAINS LOT Lot Block Unit _OPEN COLUMBARIUM NICHE Niche Block Unit BURIAL DATE AND SERVICE TIME: g f33 j FOR DECEASED: 0;3 /C Ary name NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership) 4 Name Signature Date I 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. Name t Signature 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 Cem ////g�DD Q etery �exto /T// Date 1 W This forfTi to be provided to Clerk's Office by Sexton for permanent record upon completion. 1. Name of First Mid le Last Deceased Josephine Kopecky Date Month Day Year of Death 02/15/2011 2. Place of Death City, Town or Location County Indian River Sebastian Name of (If neither, give street address) Hosp. or Inst. 9650 -1 Estuary Way, Sebastian, FL 3. Name of Medical Certifier Michael A. Venazio Address 8005 83rd Avenue Sebastian, FL 32958 Phone Number 772/388 -2110 nMedical Examiner C Physician 4. Name of Funeral Home /Direct Disposal Establishment Strunk Funeral Homes Crematory i a N. Central Avenue Sebastian, Fl 32958 Fla. Lic. No. /Reg. No. F041870 Phone No. (Area Code) 772/589-1000 5. Check Appropriate Box 6. Funeral Director/ r B. D. FLORIDA DEPARTMENT OF HEALT YPE Method of Disposition: MBURIAL DCREMATION Signature of Sexton or Person -in- Charge a. 0 c. DH 326, 8/97 (Obsoletes all previous editions) (Stock Number: 5740- 000 0326 -2) The medical certification has been completed and signed. A completed certificate of death accompanies this application. State of Florida, Department of Health, Vital Statistics APPLICATION FOR BURIAL TRANSIT PERMIT b. 21 Joan was contacted on 02/15/2011 He /she verified that this death was from natural causes, that there was no accident nor other external cause of death, and that Michael A. Venazio, M.U. will complete and sign the medical certification of cause of death within 72 hours. medical certification of cause of death within 72 hours. Signature /tillt.71() He /she verified that was contacted on c. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA Medical Examiner, will complete and sign the F.E. No. /Reg. No. Date Signed F044048 02/15/2011 BURIAL TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No. 1228 -11 -0076 A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has been contacted by the funeral director and will not be able to complete the medical certification of cause -of -death section of the death certificate within 72 hours. D No extension of time for filing the death certificate h been requested. Registrar or Date Date Certificate Subregistrar Signature dt Issued: 02/15/2011 Due: 02/19/2011 Approval Number: Date Medical Examiner, gave authorization by telephone to Funeral Director /Direct Disposer. Date The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting period of 48 hours after death is required for all cremations. CEMETERY OR CREMATORY Place of Disposition 5L 94�5 6 0-,v7,=/A--/e7- i 0 STORAGE Date of Disposition 4 8 DOTHER (Specify) This permit must be endorsed by the Sexton or person -in- charge (or by the Funeral Director /Direct Disposer when there is no Sexton) and returned within 10 days to the local County Health Department in the county where disposition occurred. Distribution: White: Cemetery or Crematory Yellow: Funeral Director or Direct Disposer Pink: Local Registrar Area Code Phone Number QnOf SL STLAN 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, residence of purchaser or person for whom lot is intended for interment must be provided at time of purchase /1 it Ky Names' 7‘. sa s f iQy 11)i9y/ 44 644.9 Address 772 5 6 9 7� Residence Address of Intended Occupant if Other Than Purchaser Office Use Only Receipt is acknowledged in the sum of: Additional Fees paid at time of purchase: Vase and Ring for Niches (cost) I:1W W- DATA \Ms- Cemetery\RECEIPT.doc Signature of Purchaser /City of Sebastian Service fees are to be paid at time of need only Dollars fd° 6 G on this I2 day of ,d 20e/ for the purchase of the following described Cemetery Lot(s) and /or Niche(s). Unit 5/ Block Ll C, Lot(s) 5 Niche(s) for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. Comer Markers (set of 4 $20) Opening Closing W 0 H Circle One Interment Disinterment 7':'. QD December 9, 2004 Ms. Josephine M. Kopecky 9650 Estuary Way, No. 1 Sebastian, Fl 32978 Dear Ms. Kopecky: HOME OF PELICAN ISLAND 1225 Main Street, Sebastian, F132958 Telephone (772) 589 -5330 Fax (772) 589 -5570 Enclosed is City of Sebastian Certificate 1994 for the purchase of Cemetery Lot 35, Block 40, Unit 4. Also enclosed is a copy of your receipt and the Rules and Regulations governing the Sebastian Municipal Cemetery. If you have any questions, please contact our office. Sincerely, Sally A. Maio, MMC /CMC City Clerk SAM:ar enclosure QiY# sffriAN SL JOSEPHINE M. KOPECKY PH 561 -589 -7826 9650 ESTUARY WAY, NO 1 SEBASTIAN, FL 32958 PAY 7 Vero Beach, AL 32960 FOR L d t" S I: 26 7084199:2 2 3000 10 9 71. •HMO No. 001001 208001 001501322900 001501341920 001501 341910 001501 341930 601010 343800 CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT Sales Tax Garage Sales CopieslBid Specs. LDCICode of Ordinances Election Qualifying Fees %�-i- Otf� P DATE .471-S 717,4 7 d a o el 0 L ©o DOLLARS 1r HARBOR CLUB 310 08 VA i Dp f w Finance Pink Applicant 59fr 3194 Amount Paid Cemetery Lots /De Oa LoUN i Block Unit 001501 343805 Cemetery Fees Total Paid d• Od 0833 63- 8419/2670 BRANCH 003 Paid by CEMETERY Receipt No List Price 400.00 Maximum No. Burial Spaces Monument permitted Edward Fevang interred Lot 36 2/6/91 (Data above this line for City Record only) Net Paid 400.00 THIS INDENTURE MADE This 6th between the City of Sebastian, a municipal corporation existing under the laws of the State of Florida, as Grantor and Mrs. Helen Fevan 573 Benedictine Terrace Sebastian 32,9.58 of the County of ..IndU..an RI-x r and State of Florida as Grantee, WITNESSETH: That the Grantor for and in consideration of the sum of 400 00 to it in hand paid, the receipt whereof is herewith ac- knowledged, does by this instrument grant, bargain, sell, release, convey and confirm unto the Grantee her heirs, legal representatives and assigns the following property situated in Sebastian, Indian River County, Florida, to -wit: All of Lot(s Book 2, at in Indian s 3 Block, 40 UNIT 4 of Sebastian municipal cemetery as per Plat Number 1 thereof recorded in Plat e 65 of the public records in the office of the Clerk of the Circuit Court of St. Lucie County of Florida; said land now lying and being er County, Florida. To Have and to Hold the same forever; provided that said property shall be used solely and exclusively for the interment of e human dl and shall be used, kept and maintained at all times in accordance with the rules and regulations, ordinances and resolutions of the City of stun, Florida, hereto- fore, now and hereafter adopted or provided for 'the government and operation of said cemetery. The conditions, restrictions and requirements contained in this instrument shall be covenants running with the land. In the event of the failure of the owner of any property situated within said cemetery to ob- serve and comply with such rules, regulations, resolutions and ordinances and the conditions of the deed of conveyance thereof then the title of such owner in and to said property shall terminate and the same shall revert to the City of Sebastian, Florida. IN WITNESS WHEREOF, The said party of the first part has caused this instrument to be executed in its name and on its behalf by its Mayor and attested by its City Clerk and its corporate seal to be hereto affixed, the day and year first above written. Si:ned, Sealed and Delivered I the rence o(: STATE OF FLORIDA MITI" Am T1TTT A 17 TsImmow 658` 6 City Clerk QIruirt rj Breit i. Dated Qit1 of $Ptastian 2/6/91 day of February CITY OF SEBASTIAN, FLORIDA By is 35, 36 )ck 40 Unit 4 NO. 1312 Helen Fevang 573 Benedictine Terr. Sebastian,Florida 32958 c o /"13i2 (laity a $eal) 1 A. D., 19.. 1