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HomeMy WebLinkAbout4-09-29Cf1Y OF HOME OF PELICAN ISLAND Certificate No. 2131 ~~ Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Jennifer Johnstone Smith 1066 N. E. Daytona Drive, Palm Bay, FI 32905 (name) (address) In and for consideration of the sum of $1,125.00 is entitled to full interment rights in the Sebastian Municipal Cemetery for the following Lot(s)/Niche(s) U n it_4_Block_9_,Lot(s) / N iche_29,_, of the Sebastian Municipal Cemetery, as maintained on file in the records of the City Clerk for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. CONVEYED THIS 22"d day of May, 2007. OF/~~ASTIAN, FLORIDA AI Minner ty Manager ATTt~ST,: -~ _ ~~~' Sal~yy A. Maio, MMC 'f City Clerk ~~~' QF ~~r May 22, 2007 Jennifer Johnstone Smith 1066 N. E. Daytona Drive Palm Bay, F132905 RE•• Interment Rights to Unit 4, B/ock 9, Lot 29 Sebastian Cemetery Dear Ms. Smith: Enclosed is City of Sebastian Certificate 2131 entitling you to full interment rights in Unit 4, Block 9, Lot 29. Also enclosed is a copy of the Rules and Regulations governing the Sebastian Municipal Cemetery. If you have any questions, please contact our office. Sinc t ~ ' ~` Sally A. o, MMC City Clerk SAM:ar enclosures ~~ ~~, ----~ City of Sebastian Municipal Cemetery Purchase Receipt .. ,... Area Code & Phone Number ~~,3~ Residence Address of Intended Occupant if Other Than Purchaser Dffice Use Only Receipt is acknowledged in the sum of: Dollars ($ D Q ) on this day of , 200_ for the purchase of the following described Cemetery Lot(s) and or ' fiche(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: Comer Markers (set of 4 - X20) Opening & Closing „.,~~y_ W O H Circle One Vase and Ring for Niches (cost) Interment Signature of Purchaser of Sebastian Disinterment TOTAL $ / ~.So . oa Service fees are to be paid at time of need only I:\W W-DATA\Ms-CemeterylRECEIPT_doc 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 ENNIFER JOHNSTONE SMITH asp ~~ z i - ~"`~ y - `~ l ~ l 1066 N.E. DAYTONA DR. PAI~A BAY, FL 32905 _ ~ to '~~8 i ~-os _- =- _.: Z / Z~ ~- Dai___-_- -- Ban~cofAmerica~~.~~ ACH R(f 707000327 (~~ ~ / Mem--_-~ --- i: LO 7000 3 2 7~: 4 39000 C d c N G m i 0 O m I 0 E I _T m v 0 ~ ~ s ~o -o d c ~ ~ ^nJI -J 0 0 0 0 0 0 0 0 o ~ ~ ~ ~ o 0 0 0 0 0 0 0 W W W A N ~ A A A O ~ W cD _ cD t0 N CO ~ O O O O O O ~ C J~ O ~ o ~ ~ v o m m m Z m ~~' - n ~ m m ~ ~ ~ ~ C7 y m w ~ p ~. a ~ x m or m ~ ~ N H ~ ~ ~ ~ ~ n T ~ ~ n x c ~~ ~~ ~ ~ 0 n m O1 ~ ~ x ~ u ~ ~~ 0 c v Q n n ~ ~ m~o m ~ m ~ N CD -1Q~ T ~ n D mZ ~ ,. N Name ;'"~~l~ ~ .~}:#=`t~~' ~1 ~,.4. ~ s-- ~~(fG.:• ~. ~~ C Unit ~"~ Block ,t Lot Date of Mark-out ! ~ ~ ~ ~. Date of Burial ~ '`r' h~~`„ y lime _~ -' ,,^~ ~, Name of Funeral Home Authorized by -~~~'0 FLORIDA DEPARTMENT OF HEALT A. (TYPE) 1. Name of First Deceased 2. Place of Death County BREVARD 3. Name of Medical . D State of Florida, Department of Health, Vital Statistics APPLICATION FOR BURIAL -TRANSIT PERMIT MARAGRET City, Town or Location PALM BAY Certifier JOHN R. CAMPBELL, nMedical Examiner I " Name of Funeral Home/Dired Disposal Establishment SEAWINDS FUNERAL HOME 4. 5. Check Appropriate Box 6. Funeral Director/ Direct Disposer a. MD Address 735 FLEMING STREET SEBASTIAN, FLORIDA 32958 2617 ~ 772-589-1933 The medical certfication has been completed and signed. A completed cert~cate of death accompanies this application. b ~ was contacted on He/she verified that this death was from natural causes, that there was no accident nor other external cause of death, and that will complete and sign the medipl certfication of cause of death within 72 hours. c ~ was contacted on He/she verified that Medical Examiner, will complete and sign the medical ification of cause of death within 72 hours. t aturer ~ F.E. No./Reg. No. Date Signed ,~ ~f ~ ~_ 22,94 MAY 21, 2007 B BURIAL -TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No. 07-2617-088 A five (5) day extension of time for filing the death certificate (exGusive 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 cert~cation of cause-of-death section of the death. certificate within 72 hours. ~No extension of time for filing the death certificat ~as been requested. Registrar or ` Date Date Crtficate i; SubregistrarSignature ~~'~---°"" Issued: MAY 2-1, 2007 Due: MAY 25, 2007 _ O. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-ATSEA 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. Awaiting period of 48 hours after death is required for all cremations. p. CEMETERY OR CREMATORY Method of Disposition: Place of Disposition SEBASTIAN CEMETERY ©BURIAL STORAGE Date of Disposition ~ v2 CREMATION Signature of Sexton or Person-in-Charge OTHER (Specify) Middle Last Date Month Day Year of DOUCETTE ~ Death MAY 17, 2007 Name of (If neither, give street address) Hosp. or Inst. WILLIAM CHILDS HOSPICE HOUSE Phone Number This permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when mere Is no Jexw~i~ a~ ~.. ~~.~, ~~~~ within 10 days to the local County Health Department in.the county where disposition occurred. 5200 BABCOCK STREET, NE PALM BAY, FLORIDA 32905 321-984-4045 Fla. Lic. No./Reg. No. Phone No. (Area Code) Distribution: ~~: F ~ la Director or Direct Disposer DH 326, 8197 (Obsoletes all previous ed~ions) Pink: Local Registrar ~ `~ ey. (Stock Number 5740-000-0326-2)