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Home My WebLink About1-28-29 i f Name Si,Xi//Pg. 4) .V O A, • ix e 3 Jac.. Unit / Block E3* Lot 45?• Date of Mark-out `6//Z7 3 • Date of Burial ll//3/l 3 • Time °49 . (71/11.14-5 1b Name of Funeral Home e0Y /PICX rJ Authorized by WAiltairrVa- I CITY OF SEBASTIAN rl CITY CLERK'S OFFICE 4 8 1 J RECEIPT Name /' C'he- /)71 CL f I n ❑ Cash I Date � I — r q -�� [Check# /'1 l b No. Amount Paid 001001 208001 Sales Tax 001501 322900 Garage Sales 001501 341920 Copies/Bid Specs. 001501 341910 LDC/Code of Ordinances 001501 341930 Election Qualifying Fees 601010 343800 Cemetery Lots u 1 •GC Lot/Niche 2-9 ,Block Z v ,Unit , 001501 343805 Cemetery Fees Q/C, /60,o /rYtyi Total Paid /15-6 Initials White-Dept.of Origin• Yellow-Finance •Pink-Applicant 103635 STATEMENT DATE /1/17/3 _ TERMS TO ADDRESS J/4X /J4 f /!y IN ACCOUNT WITH 54/54 7-/—i‘ti,/ 67-/E4/' /g / A40.4 H7 „f . ,a,ec A/4 s I ei/c - / � SLY", 0 - A r-, - �� AW• - (I) 014 /5-15. oT� / � /6 - f7 .d..er DC5812 FllD3 II'ARrbi4r 0F'�r J% ,.' State of Florida, Department of Health, Bureau of Vital Statistics HEALT BURIAL TRANSIT PERMIT DATE PRINTED:November 12,2013 TRACKING NUMBER: 2013158818 DECEDENT INFORMATION Date of Death Name of Deceased November 8,2013 JENNIFER ELLEN DOLAN Town or Location Name of facility,or street address if not a facility Place of Death-County City, 16674 96TH TERRACE NORTH PALM BEACH JUPITER Fla.Lic.NoJReg.No. Phone Number Name and Address of Funeral HometDirect Disposal Establishment F0 Fla.Lic. Phone 287-1985 Number TREASURE COAST SEAWINDS FUNERAL HOME&CREMATORY F073381 950 SE MONTEREY ROAD STUART,FLORIDA,34994 Fla.Lic.NoJReg.No. Funeral DlrectorlDirect Disposer 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: 0 iif...44.CZ. T - Date Issued: November 9,2013 Meade Grigg,State Registrar 3. AUTHORIZATION for CREMATION,DISSECTION, BURIAL-AT-SEA,or HOSPITAL SDI DISPOSITION Authorization given by Medical Examiner District 15 Approval Number: 4. C CEMETERY OR CREMATORY Place of Disposition: 7 t 4345 t 1 At ii c Ew e-'t' 3 Method of Disposition: B V 12.1 IH L Date of Disposition: EDRS maintains all statutorily required information regarding the death record and related i 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 FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY SEBASTUMN HOW O1 PILKAN 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 W-UNERA-6-14044E; 77TY /4-4)97, 17 ADDRESS: PHONE #: • . (Check One) _,)OPEN BURIAL LOT Lot AF Block rlk Unit OPEN CREMAINS LOT Lot Block Unit _OPEN COLUMBARIUM NICHE Niche Block Unit W BURIAL DATE AND SERVICE TIME: (t),A //3/1.3 II,/J,(c-0,4✓E 5!Cpl FOR DECEASED: "T',�/y,,y y�E �, X00077 v 4 itt. rvame NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership) 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. ///4 • Name '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 _A, ////2 Cem to exto Date/2E.ry� This form to be provided to Clerk's Office by Sexton for permanent record upon completion. y J `. 7 a• ' :~ ` K' p' e~k,< 5 k G~r~, 9.e, c.. 2 ~~ .- C r ~~ ._`,d ~~ _ Bp~oNB •., iTy ~ ten` ` c`r~ . .~ .. ~u,~. ,~ H~ , / . N ID ~ ~ fin: a `u .,. -~-~~ r am ~~ ~~~ HOME OF PELICAN ISLAND Certificate No. 2115 Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Anna M. Kielbaey (name) 1172 Breezy Way, Sebastian, FL 32958 (address) in and for consideration of the sum of $700.00 is entitled to full interment rights in the Sebastian Municipal Cemetery for the following lot: Unit 1_ Block _28_ Lot 29_ of the Sebastian Municipal Cemetery, as maintained on file in the records of the City Clerk for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. CONVEYED THIS 23rd day of February, 2007. ~TIAN, FLORIDA " A1~Minner City Manager ATTEST: i`' -. ~.' ~.: Sally .Maio, MMC `City Clerk Lac r 1 i`9 a j ~ r f~ r v. _~; _a February 27, 2007 Ms. Anna M. Kiellbaey 1172 Breezy Way Sebastian, FI 32958 RE.• Interment Rights to Unit 1, Block 28, Lot 29, Sebastian Cemetery Dear Ms. Kielbaey: Enclosed is City of Sebastian Certificate 2115 entitling you to full interment rights in Unit 1, Block 28, Lots 29. Also enclosed is a copy of the Rules and Regulations governing the Sebastian Municipal Cemetery. If you have any questions, please contact our office. Sinly, \\ ~i~,,_______._ Sally A. io, MMC City Clerk SAM:ar enclosures ~-l ~~ ~« S~BAST~ _,~~. HOME OF PELICAN ISLAND City of Sebastian Municipal Cemetery Purchase Receipt To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate regulations, residence of purchaser or person far whom lot is intended for interment must be provided at time of purchase Name(s) Address Area Code & Phone Number ~~,~ ~_ Residence Address of Intended Occupant if Other Than Purchaser Office Use Only Receipt is acknowledged in the sum of: Dollars ($ 74c'-o~ ) on this o~~ day of C"c-~- , 200 7 for the purchase of the following described Cemetery Lot(s) and/or Niche(s). Unit ~_, Block ~~ ,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 - $20) Opening & Closing Vase and Ring for Niches (cost) Interment Disinterment W O H Circle One TOTAL $ 7C~ o° 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 ;`" ~ 1239 AIVNA_M. KIELBAEY os-o6, ~~ 7.172, i312EP.ZY INAY - ~" _~~ ~~ SBRASTI ~1N, TG, 32958: i ~ ~ ~ ~ ~ ~ ~ 0 7 sa-visa i F~ sao P,~j-i~,ih~~ ~~L a ~/~;~i_ ~<~> ,J p ~ ~ ,:~ ~ Dollars ~ ~. BankofAmeric ~~~~ ACH H/T 063100277 For ~ ~~.~%~ fi ^ ^ y ,,, t.063L002 7~. 00229L4567331i'L239 CITY OF SEBASTIAN CITY CLERK'S OFFICE ~ ~-'~ RECEIPT .Name ~ ~ f'~ ~ ~ ~~ ~' ~:/ ^ Cash Date ~ ' ~ . ~ '" ~.~ Vf ~ Check# No. Amount Paid 001001208001 Sales Tax 001501322900 Garage Sales 001501341920 Copiesl8id Specs. 001501341910 LDCICode of Ordinancs3s 001501341930 Election Qualifying Fees 601010343800 Cemetery Lots _~~, LotMiche ~ Bl k C ~ i f U ~ oc . n t 001501343805 Cemetery Fees ~~~~~`~`j Total Paid C.~~t•~~~ Initials. ?`~ White -Dept. of Origin . Yellow -Finance • Pink -Applicant