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Date of Burial 7/Z, 1/,3 - Tlme 'S
Name of Funeral H7 /4 All',
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Authorized by `��
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
SEBASTIAN
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For information contact:
Kip Kelso - Cemetery Sexton
Sebastian Municipal Cemetery
(772) 589-2545
City Clerk's Office
City Hall, ?225 Main Street
Sebastian, FL 32958
Office (772) 388-8215 or 388-8214
Fax. (772) 589-.5570
FUNERAL H( family
ADDRESS
PHONE #:
(Check One)
---OPEN ♦1f BURIAL LOT Lot Block Unit _ _
OPEN CREMAINS LOT Lot -31-A --Block 13 Unit 4
.OPEN COLUMBARIUM NICHE Niche_ Block - —Unit -
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BURIAL DATE AND SERVICE TIME: 9/20/19 / 11:35 A
FOR DECEASED: Michael J - Gillespie
Name
14AME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE'
(Must provide proper documentation of ownership)
Name Signature Dale
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 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 at all fees have been paid
e leryext n Date
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.
**** The gravedigger that does the services for our Funeral Homes are
A - B - C - Vaults the owner's name is : George, the phone # is
1(772) 332 - 8175
CITY OF SEBASTIAN 11886
ADMINISTRATIVE SERVICES RECEIPT
Name r /I PSP, 6 ❑ Cash
Date 9lasiliq �dDhecka�47
O Credit
Amount Paid
001501 362150 Non -Tenable Rent
001001 220000 Security Deposit
001501 362100 Taxable Rent
001001208001 Sales Tax
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 220030 PD SHOP
001501366602 PD SAFE
001501366603 PD COPE
001 1 3�13Ec1S DIG , Do
UNrr If 8LK 13 LD -r 03A
Total P� gyp, 00
Initials
White - Dept. of Origin - Yellow -Admin. Svcs. - Pink -Applicant
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HOME OF PELICAN ISLAND
Certificate No. 2117
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Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian,
it is hereby certified that:
Michael J. Gillespie
(name)
305 Georgia Boulevard, Sebastian, FL 32958
(address)
in and for consideration of the sum of $1,050.00 is entitled to full interment rights in
the Sebastian Municipal Cemetery for the following lot:
Unit 4_ Block _13_ Lots_ 31a, 32a & 33a_
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 2nd day of March, 2007.
CITY OF SEBA,STIAN, FLORIDA
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Sal A. Maio, MMC
' City Clerk
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HOME OF PEUUN 15tANla
Burial rights in the Sebastian Municipal Cemetery lots/niches purchased by me
(Please print name and address oT pi�rchaser�
(�n�f �i . 13lock 13
(Lot/niche, b{ock, unit description)
are intended for interment of the following individuals:
Ptease print name(s):
�31-A) /j�1}� � I
I I! i f 11�i i�' �� �'1 � L
� 32 - �,, �J��n�,s (�► I l �� i � _ _
( 33-A)
Iriterment lots/niches are not to be transferred without written approval of the City of
Sebastian. Interment lots/niches in the Sebastian Municipal Ceinetery are allowed to be
passed on to heits bu1 the City requires a certified copy of relev�int probate or other
court documents.
1 have read and unders Ihe terms of this agreement.
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5tgn ure Date
�Su scribed end� b m �.. efora , me this � �doy of _. _ �l� Dy
� who Is y�ers� orfelry known Io me, O! hA3 produeed
r as Identificetl�n.
Nolary Public, State of orida
N�mec oi IMerteO torm
G�,�.
���tpN1' PVer DONNA F. GARDNEH
_'r°• .`�= Notary Public - State of Florida
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's' + .•= My Comm. Ezpires Mar 19, 2016
=,�.F �°; Commission � EE 18084t
,, o` �`'� Bonded Through National Notary Assn.
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March 2, 2007
Mr. Michael J. Gillespie
305 Georgia Boulevard
Sebastian, FI 32958
RE.- Interment Rights to Unit 4, B/ock 13, Lots 31a, 32a & 33a, Sebastia� Cemetery
Dear Mr. Giliespie:
Enciosed is City of Sebastian Certificate 2117 entitling you to full interment rights in Unit
4, Block 13, Lots 31a, 32a & 33a. Also enciosed is a copy of the Rules and
Regulations governing the Sebastian Municipal Cemetery.
If you have any questions, please contact our ofFce.
Sin ly, -, �
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'�.__ .� � �
Sally A. aio, MMC
City Clerk
SAM:ar
enclosures
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City of Sebastian Municipal Cemetery
Purchase Receipt
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To enable the City of Sebastian to determine the correct rate, and in a.ccordance with cemetery
rate regulations, residence of purchaser or person for whom lot is intended for interment must be
%`�� -- �.S � �/- .Z� t� � •
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
O�ce Use Only
�e. ..�.L.�i..ulr.rlr.�ii in 4h� �.��m nf•
on thi�.�,�� _ day of�
described Cemetery Lot(s)
s).
ars ($� �.5�� O�
2Q��for the purchase of the following
Unit ��, Block _�_, Lot( � �� 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:
Comer Markers (set of 4-$20) Opening & Closing
W O H
Circle One
Vase and Ring for Niches (cost) Intermen.�'' Disinterment
f�I �� O AL $ O, C� �
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ignature of Pur er City of Sebastian
Service fees are to be paid at time of need only
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' MICHAEL J. GILLESPIE
305 GEORGIA BLVD
SEBASTIAN> FL 32958
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