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Home My WebLink About4-10-38Name/, f+� / C� A1,4d /, 5 / Unit Block Lot C2 T7> Date of Mark -out Date of Burial j-Z 3- Z/:s Time Name of Funeral Home 5,e s. ♦u/ Authorized by Total Paid 15a.. oy Initials White - Dept. of Origin • Yellow - Finance • Pink - Applicant CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT 4375 Name�J1 VCash Date ' / v ❑ Check # No. Amount Paid 001001208001 Sales Tax 001501322900 Garage Sales 001501341920 Copies/Bid Specs. 001501341910 LDC /Code of Ordinances 001501341930 Election Qualifying Fees 601010 343800 Cemetery Lots ``�� LoUNiche �3 Block V Unit 4 001501343805 Cemetery Fees d/G 155.00 Total Paid 15a.. oy Initials White - Dept. of Origin • Yellow - Finance • Pink - Applicant LEOLA B. GNACINSKI Leola B. Gnacinski, 74, Sebastian, FL, passed away on April 30, 2013 at her residence. She was born on October 1, 1938 in Erie, PA and had been a resident of Sebastian for 18 years. Before retiring she worked as a coil winder for General Electric. She was a member of the Fraternal Order of Eagles in Sebastian, FL. Mrs. Gnacinski is survived by daughters, Valerie King, Sebastian, FL, Rebecca Jennings, Micco, FL, son, Tim King, Barefoot Bay, FL, sister, Betty Cole, Edinboro, PA, 4 grandchildren and 3 great - grandchildren. Mrs. Gnacinski is predeceased by husband, John Gnacinski, and a son Brian King. Certificate No. 2157 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: John Vor Leola Gnacinski 475 Watercrest Street, Sebastian, FL 32958 (name) (address) In and for consideration of the sum of $2,000.00 is entitled to full interment rights in the Sebastian Municipal Cemetery for the following lots: Unit_4_Block_10_ Lots _38 & 39_ 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 6th day of December, 2007. EBASTIAN, FLORIDA ATTE �Al Minner ity Manager Sally A.,�laio, MMC City Clerk CRY Of HOW 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 6hn 4- ,Le-v(Q (IIlab ns k►' Name(s) 14"75 Str et �Sf�'ctllLZ�i5� Address ( -I -I a).'A SIR -&- Area Code & Phone Number Residence Address of Intended Occupant if Other Than Purchaser Office Use Only Receipt is acknowledged in the sum of: •�ll,(I b _th-RkA aA& aA6L'� Dollars ($4 060, 00 ) on this (D�= day of J1C , 20_Q] for the purchase of the following described Cemetery Lot(s) and /or Niche(s). Unit 4, Block , Lot(s) 4- 3q 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 Vase and Ring for Niches (cost) Interment Disinterment W O H Circle One TOTAL $DULL , U ign6atl-u�reof Purchaser City of Seb tian Service fees are to be paid at time of need only I: \W W- DATA \Ms - Cemetery\RECEIPT.doc 1225 Main Street, Sebastian, FL 32958' (772) 589 -5330 — Fax 772 - 589 -5570 December 10, 2007 John & Leola Gnacinski 475 Watercrest Street Sebastian, FL 32958 RE: Interment Rights to Unit 4, Block 10, Lots 38 & 39 Sebastian Cemetery Dear Mr. & Mrs. Gnacinski: Enclosed is City of Sebastian Certificate 2157 entitling you to full interment rights in Unit 4, Block 10, Lots 38 & 39. Also enclosed is a copy of the Rules and Regulations governing the Sebastian Municipal Cemetery. If you have any questions, please contact our office. Sincerely, Sally A. Maio, MMC City Clerk SAM /jw Enclosures 099079 Date TO / TERMS IN ACCOUNT WITH I Ro J bzg A r . Al Stock Form 25812 F1ARlD3DFI' State of Florida, Department of Health, Bureau of Vital Statistics HEAL BURIAL TRANSIT PERMIT DATE PRINTED: May 1, 2013 TRACKING NUMBER: 2013064706 1. DECEDENT INFORMATION Name of Deceased Date of Death LEOLA B GNACINSKI April 30, 2013 Place of Death - County City, Town or Location Name of facility, or street address H not a facility INDIAN RIVER SEBASTIAN 475 WATERCREST STREET Name and Address of Funeral Home/Direct Disposal Establishment Fla. Llc. No. /Reg. No. Phone Number SEAWINDS CREMATORY F073383 F073383 (772) 589 -1933 735 SOUTH FLEMING STREET SEBASTIAN, FLORIDA, 32958 Funeral Director /Direct Disposer Fla. Lic. No. /Reg. No. ANTHONY GABBARD F044749 2. BURIAL - TRANSIT PERMIT The Florida Department of Health, Bureau of Vital Statistics nerehy graria per ifisaw f6 dtSP6se of this b6dy trf adtb6rdaff0e 4i/ifh Chapter 382, Ft6fida Statutes. Permit Number: 2013- FO73383 -5034 • Q p /� j Date Issued: April 30, 2013 `t• �J Meade Grigg, State Registrar 3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL -AT -SEA, or HOSPITAL DISPOSITION Authorization given by Medical Examiner District Approval Number: 4. CEMETERY OR CREMATORY Place of Disposition: SEBASTIAN CEMETERY Method of Disposition: BURIAL Date of Disposition: EDRS maintains all statutorily required information regarding the death record and related 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 / /°e Lo 5 3-u /,&( -0 FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY M,., HOME Of PELICAN 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 FUNERAL HOME: t>C111 w ✓L S ADDRESS: 7 3 S- S PHONE #: i -1 c1- t � 3 3� 0— k 1-tc Pm �- e. (Che One) OPEN BURIAL LOT Lot i� Block, Unit OPEN CREMAINS LOT Lot Block Unit OPEN COLUMBARIUM NICHE Niche Block Unit N S E W BURIAL DATE AND SERVICE TIME: a FOR DECEASED: lzo L cL 6A/mclintKi Name NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership) /y /' 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 DI ECTOR: /7rtflioo� 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: 5' Cem to Se on Date This form to be provided to Clerk's Office by Sexton for permanent record upon completion.