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MY OF
L
HOME OF PELICAN ISLAND
Certificate No. 2097
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:
Alfred G. Moore
(name)
142 Coconut Street, Sebastian, FL 32958
(address)
in and for consideration of the sum of $1,800.00 is entitled to full interment rights in
the Sebastian Municipal Cemetery for the following plot/niches:
Unit 4_ Block 31_ Niches 61 E, 62 E
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 5th day of September, 2006.
CITY W SE )9)(STIAN, FLORIDA
Manager
ATT
7
Sall . Maio, MMC
City Clerk
c
it
Name�L
Unit
Block
Lot
Date of Mark -out /
Date of Burial l?+ e�o ! Time
Name of Funeral Hom �� y
1
Authorized by
[ it
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
SEA {AIN
"Omi of vEUCA AN
H ISLD
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
FUNERAL HOME: /t,, /, /0 5 0
ADDRESS: '
PHONE #:
(Check One)
_OPEN BURIAL LOT Lot - Block Unit
BEN CREMAINS LOT Lot Block Unit
PEN COLUMBARIUM NICHE Niche 61 Block Unit
,E. W
BURIAL DATE AND SERVICE TIME:
FOR DECEASED: klZe C n c 4 -
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 DIRECTCiR
Name 'Signature Date
---------------------------------------------------------------------------------------------------------------------- - - - - -- --
Cemetery Sexton Certification:
I certify that I have checked the ownership inforn-vion by viewing the owner's deed and confirming
with Clerk's office Lind that all fees have been paid
?. - Z
-Cer;6eter/Sexion Date
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.
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C" or
SEBASTMN
HOME OF PELICAN ISLAND
City of Sebastian Municipal Cemetery
Purchase Receipt
D eed it 20R 7
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
LFRED G. /MMonee-
Names)
Address
77a-- s39 5/7&
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Receipt is acknowledged in the sum of:
(Q. Jjhft jwxd4a i Dollars ($ 0'U^
on this day of , 20 for the purchase of the following
described Cemetery Lot(s) and /or Niche(s).
Unit, Block , Lot(s) Niche(s) 61 E-As f, 6Z 6 QS f
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 1 �-# oo W O H
Circle One
Vase and Ring for Niches (cost) 4q, *� Interment
Disinterment
TOTAL $ 19 R4 4 q
yi?
JAL& Wj#'t4'zW4,----
Signa ure of Purchaser ' y of Sebastian
Service fees are to be paid at time of need only
I: \W W- DATA \Ms - Cemetery\RECEIPT.doc
CITY OF SEBASTIAN 4333
CITY CLERK'S OFFICE
RECEIPT
f� ^ n
Name
Date /Z�- _ l
No.
001001 208001 Sales Tax
001501322900 Garage Sales
001501 341920 Copies/Bid Specs.
❑ Cash
Check #
Amount Paid
001501 341910 LDCICode of Ordinances _
001501341930 Election Qualifying Fees
601010 343800 Cemetery Lots f
LoMiche lU , lock \' , Unit
001501 343805 Cemetery Fees
i
Total Paid 313'
s
White - Dept. of Origin a Yellow - Finance • Pink - Applicant
peed *.F6R7
C" or
SEISASTMN
ROME OF YPELICAN 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
L-f RED G. MaaeC
Name(s)
Address
7Za- .139 917&
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Receipt is acknowledged in the sum of:
i
L .![.t_ O,
on this day of , 20.
described Cemetery Lot(s) and /or Niche(s).
Unit_, Block 3 �, Lot(s
for the purchase of the following
Niche(s) 61 F-(ls f 62 L QS
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 j `t,J , W O H
Circle One
Vase and Ring for Niches (cost) " Interment
Disinterment
TOTAL
Y/la.rt e _
Signature of Purchaser ' y of Sebastian
Service fees are to be paid at time of need only
I: \W W- DATA \Ms - Cemetery\RECEIPT.doc
B
Cus�)
/iPJD.P�'
ALFRED G. MOORE 210396 2128
MERCEDES K. MOORE 08029107
142 COCONUT STREET
SEBASTIAN, FL 32958 DATE
PAY TO THE (/� , /- .��y
ORDER OF l� / 4Z 60c -- e44cST� >l I $ /yy
DOLLARS 8
CITY OF SEBASTIAN
CITY CLERK'S OFFICE 2 1 213
Name 211
f nv l� oo re
0 Cash
Date - n
X Chec Lo.2
No.
unt Paid
001001 208001
Sales Tax
001501322900
Garage Sales
001501341920
Copies/Bid Specs.
001501341910
LDC /Code of Ordinances
001501341930
Election Qualifying Fees
601010 343800
Cemetery Lots
=F00
Lot/Niche& I E Block 3 (_
Unit
,
E
001501 343805
Cemetery ee
-Vpen + a OS Ina
tf5oo
✓aLS e ,� r i nQ
4q,q4
Initials
Total PaioRgq g4
Whi - Dept. of Origin . Yellow - Finance a Pink • Applicant