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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
!~0 (/l a. l d ~ ~VIC,! ~ ~ L-o ~c Iii/~l ~ ~ n iii
Name(s)
~ 3 3 De l i'Vl o ~ to ~oG~G~~ ~S~IoQS f r Q ~ ~ ~ 3 Zg 5~'
~~7a)5~sq-~.v~
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Receipt is acknowledged in the sum of:
~(, ~ Dollars ($ /`~~0. ~D )
on this ~- ~~' day of ~Q~1 i,~2r~, 20 c~~7 for the purchase of the following
described Cemetery Lot(s) and/or Niche( ).
Unit ~ ,Block ~~ ,Lot(s) l5, ~ / (o Niches
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) Interment
W O H
Circle One
Disinterment
TOTAL $ I~U~, ~ ~
~~. h~ ~ A
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