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HomeMy WebLinkAbout3-COL-13SsCFTY OF HOME OF PELICAN ISLAND Certificate No. 2165 CITYOFSEBASTIAN Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Pedro & Rocio Quevedo 733 Wimbrow Drive, Sebastian, FL 32958 (name) (address) In and for consideration of the sum of $1,200.00 is entitled to full interment rights in the Sebastian Municipal Cemetery for the following niche: Unit 3 Col Niche 13Ss 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 1St day of February, 2008. CITY OF SE ASTIAN, FLORIDA ATTEST: Al Minner Sally A. aio, MMC Manager ity Clerk Name Unit Block Lot J 5 Date of Mark -out Date of Burial 3 •a Time t Name of Funeral Home ••5 ��'""� h Authorized by S EAWINDS CREMATORY Sebastian, Florida 735 Fleming Street - Sebastian, Florida 32958 wwwseawindsfh.com (772) 589 -1933 We hereby certify that these are the remains of GRISEL. QIIEVEDQ PEREZ Ti remains were received from SEAWINDS FUNERAL HOME Cremation Permit No. 08- 2617 -014 Issued at DADE COUNTY Date of Death JANUARY 23, 2008 Date of Cremation JANUARY 30, 2008 By SAM COBURN Cremator 3868 PEDRO QUEVEDO 63-643/670 ROCIO QUEVEDO BRANCH 00583 733 Wimbrow Dr Sebastian, FL 32958 Ph 772 - 589 -0171 — PAY TO -1 �i` ORD!7 OF WACHOVIA Wachovia Bank, N.A. w ac hovia.com 1: 06 70064 3 2 1: L I GI I r3LL,3 2SS Silo 3 In C'\i cy- MI = LU < got; I I'm 1'.. LU W d. 0 E 0 IZ U- 0) 0 CL (D - m v a� N U7 m O c —ID CD 0 E E cc cc 0 —j 0 U) (D 0 p C) O .0 rn .0 C11 N C-4 Ce) M ce) C> C) O 0 C> c=) C) C> C> = c� Cl CD C:) C> CL • • 0 Z 7g L U�3 arf OF SETT HOME Of PBLKAN 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 Pedro d- P-o e.,(`d o u e v ed o Name(s) 713 3 IA11 nlbrow Die 5th6Z6t4ati FL 3Z95e Address ( -7 T) gR -D 1 -71_ Area Code & Phone N vi.SP.I ©Lleuf.do VtreZ Residence Address okntended Occupant if Other TKan Purchaser Office Use Only Receipt is acknowledged in the sum of: Q,hL �,�",1,8'Lt,(I d Vt 0-41 & " /(H Dollars( U, ) on this 5 r day of Y" , 20 Off for the purchase of the following described Cemetery Lot(s) and /or Niche(s). Unit , BfeekLI , Lot(s) Niche(s) 1 3 S 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 , U U W O H Circle One Vase and Ring for Niches (cost) interment 40,00 ,U0 Disinterment Signature of Purchaser • );"B. . /..M.1 WY of Sebastian Service fees are to be paid at time of need only I: \WW- DATA \Ms- Cemetery\RECEI PT.doc Total Paid IniWhj Whit. - Dept of 0 a • Yellow - Finance •Pink APPlic.nt CITY OF SEBASTIAN 3960 CITY CLERK'S OFFICE RECEIPT o Cash L� Name �� 1�heckt �I Zf Date Amount Paid No. 001001206001 Sales Tax �- 001501322900 Garage Sales --- 001501341920 CopieslBkl Specs. 001501341910 LDCICode of Ordinaries 001501341930 Election 001it M Fees 601010 343600 Come" Lots <C '` � Bb& -'�_� Unit LoIINkhe r =° 001501343805 Cemetery Fees , 4 0 n 0 Total Paid IniWhj Whit. - Dept of 0 a • Yellow - Finance •Pink APPlic.nt FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY m« WW . SEBASTIAN OF Ft" swo 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 FUNERAL HOME: .�IE NVJ ► A b ADDRESS: -75-S PHONE #: (Check One) OPEN BURIAL LOT Lot Block Unit OPEN CREMAINS LOT Lot Block Unit OPEN COLUMBARIUM NICHE Niche Block Unit N S E W BURIAL DATE AND SERVICE TIME: FOR DECEASED: NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: r`(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 SIGN( /A_ TURE OF LICENSED FUNERA (RECTOR: y SAVO%. Name ignature 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: Cemet ry xton Date This form to be provided to Clerk's Office by Sexton for permanent record upon completion. TYPE Be PERMAXBff LocA1 FILE Nat BLACK lK 1�1% FLORIDA CERTIFICATE OF DEATH 1. DECEDENTS NAIVE (Pat Mwda, Lae( SethrJ 2 SDI 40, REPOmED TO MEDICAL E%AMINER DUE TO GRISEL UEVEDO PEREZ FEMALE _tkm%Wniwd 2. DATE OF BIRTH (Haft Day, Year) 4a. AGE-Last Bitlwry 41. CAUSE OF DEATH -PARTL Eaarttwlda�Lm.@®NI-twaww. rjarK «tattpMaYam- IWd(nclll cawed ttls tledt Essay macewmsiaw. ApptaMwb MWvt • (Sae ewlnAAawm bark) DO NOT Wder WmYta event swhwcadac alma. twpMaxy atrwt«vwakular mrslallon wMtow tdwW it*900kW. ; Oltwaab Oaah 5. DATE OF DEATH pUmttt Day, Year) IMEDIATECAUSE Cirttlosis of Liver 1 Abrfw Days tbtw A/adea rewlYgIn doom) ° APRIL 13 1955 52 1 I any, rWtg to UN awe Ice Found January 23.2008 - Iaed on Was & Enter the .. . 8. SOCUILSECUWrYNUMBER 7.BRTTIPIACE(CAyatfBbaa«Forfgn Cotsay) &COUNTY OF DEATH 1 • (tbsewa4jtay seat a CUBA DARE insisted the even .. ... .. .. &PLACEaFDEA11t HOSPnAt_- -"*A" - EaerwKYROWWOa4eYaa - DaWonAnNal ([irataNyans) NON-HOSPRAL: - HmidceFad* - NUwMtgNmwllapTe C -FacMy -OenrW .Halo om- s ass Alleyhearof 1 1& FACILITY NAME (Nnat i alhodM ahmo siaelf t la. CRY. T0NN1, OR LOCATION OF DEATH 116.IN81DE CITY UMITS • 42L MIAML-.. g^Yw -NO 12 MARITAL STATUS (.-f- Y) I& SURVIVING SPOUSES NAME (it wit, 9" melds M74 • _MtwW _Mallad. bd$epaMed Vrdmnd _awmed X-N.WM.,W 141L RESIDENCE -STATE tax COUNTY 140. CITY. TOWN, OR LOCATION FLORIDA INDIAN RIVER SEBASTIAN K DID TOBACCO USE CONTRIBUTE TO DEATH? 14a STRF.E'rAD0fiE39 14e. APT. NO. late ZIP CODE 14g. INSIDE CITY LaITS' 733 WIMBROW DRIVE 32958 X_Yw -No .. 150. DECEDENTS USUAL OCCUPATION(rdats 4W*fwaaclans dmW mmtafaoilleip Wa.) Donal a e71~ 150.KN0OFMJSlNESSMJDUSTRY " ' 4& IF FEMALE, WAS SHE PREGNANT WnNIN THE PAST YEAR: HOUSEKEEPING MEDICAL -Yw XNo - UMnoaa IYsAsPwIlythnesww: - awmadeath IS. DECEDENTS RACE (Specify Iw rawhaeeSbMwbill Mies! deeadadCAtwilWadllFTwNhw / as/b 6. At.. Maw raaemaybe speoaed) -Xwme - BIeckarAalan Amadan - Awmkan Indian or AWWm Naive(SpecYytrDe) • -Asian lnllat -Chiww _Fllpiw - Japaww -Karwn - Vlaiwmws -Other AsW(SysaTy) ala. LOCATION OF IN.IIRY • STATE _YBMe Havesasn _Gualwim«Chmincero - Samoan - Older Padllc Nl.(S 8cm - ONW(SPWW 17. DECEDE(roF HISPANIC OR HARBW ORKiIN? �Yw (NYas, apedyJ _No Rican �Cclwn CaaaVSaM Aerwkan -Yes _No _Meskm -Parse - (S09*1dWSderl ass ofMprttc«IWIM 04*) i • -Other (SjwOAy) - ISeXlan • 1& OE( EDETSEOUCATK )!1(9ped/yNwdvadwl'a BFjwfdapwwbvWWadaloloonpAaadY abwddx*q I&WASOECEDIENTEVERM 4Bd. APT. NO. 498. ZIP CODE U.S. ARMED FORCES? -81h Wrw - Ilghselwd bww IIiona $My�adawltlylbttes «fiE) • - College MA w d.W- CMsgs d.0-p5 -ft - Associate - BscheW. -MeeWs - Decimal -Yw g M 50. DESCRIBE NOW INJURY OCCURRED 211. FATHERS NAME (Fiat Middle, Lw6 &AV 21. MOTHER'S NAME (Fiat Middle Al"n Swww) N PEDRO QUEVEDO ROCIO PEREZ constn m sra, r ~MK wooded area) 228. WFORMNNI'S NAME M REATKWSFIP TO DECEDENT 29s. IMFORMANCS MAKING -STATE 520.7yfwW ° - Car/Mr&m - S.U.V. _Mobtcyde - PklWTnckfCatga Val - Bas PEDRO QUEVEDO FATHER FLORIDA • 296. CRY OR TOWN 23 o. STREET ADDRESS 23d. ZIP CODE SEBASTIAN 733 WIMBROW DRIVE 32958 • 21. PLACE OF DISPOSITION (Mwdcemelay, aamNay. «a6arpbee) 25a LOCATION -STATE 2W LOCATION -CRY OR TOWN SEAWINDS CREMATORY FLORIDA SEBASTIAN 2&LMErNoo OFWSPOSFnow _Saul _BAN d... -Cmnalm - Doaion -Rmwaa kam State - OfwMcW . 256. IF CREMA710K DONATION OR BURIAL AT SEA, 278. LKENSE NUMBER (dLMrww) 270. SIGNATURE OF FUNERAI. SERVICE LICENSEE OR PERSON ACTING AS SUCH WAS PPROVALCRUNTED? EXAMINER .1y i -Nat F044126 1 ► 28. NAME OF FUNERAL FACILITY 2119. F_-S MAILING -STATE " SEAWINDS FUNERAL HOME FLORIDA w 296. CRY ORTOVM 29c: STREET ADDRESS 29dZwcooE SEBASTIAN I 735 FLEMING STREET 32958 S&CERTWER _CaNybq PhyekJw-Totw bass of ay wwawtlga, death occtnreda theline.derof place, and Ass bttwawe(e) and maewraYrd 8 Iclwrxow "t' dea%ocawwdit lnw.dwswdp co dmloftcam uO wm eNW. ' Slat. J 31b. DATE SIGNED 0m4**ypj 32 TOME OF DEATH (211 fr.) S& MEDICAL EXAMINE" CASE NUMBER ► "'" �= Janus 28 2008 1 Found 09:00 11 2 1 34a. &F 340. 35, NAME OF ATTENDING PHYSICIAN (NoMMM CaBIa) 82 84 5 • 388. CEFt'IFIER'S•STATE 3tth.CffYORTOWN 38a STREET ADDRESS 3Rd, ZIP CODE s ' MIAMI MHABER ONP ON BOB HOP AD 33136 97. SIBREd57RAFi - Signal" andDar 30s. LOCAL REGISTRAR - Slptwaw DATE FILED BY REGISTRAR (M W,, a, D Yr) ISM, 3& PROBABLE MANNER OF DFAIM a 7M labs "twder /w kaladcucn d the ntedkat wmtwwr: 40, REPOmED TO MEDICAL E%AMINER DUE TO i - _Aa10al _SNelda - NOmkMe - PandtgwvwtlpeBm _tkm%Wniwd CAAMOFOEATH? _[Y" -No 41. CAUSE OF DEATH -PARTL Eaarttwlda�Lm.@®NI-twaww. rjarK «tattpMaYam- IWd(nclll cawed ttls tledt Essay macewmsiaw. ApptaMwb MWvt • (Sae ewlnAAawm bark) DO NOT Wder WmYta event swhwcadac alma. twpMaxy atrwt«vwakular mrslallon wMtow tdwW it*900kW. ; Oltwaab Oaah IMEDIATECAUSE Cirttlosis of Liver 1 (FNa dwsse - Mm 1 Years r rewlYgIn doom) ° Sa4wtwary Ilat conMotw. Chronic Ethanolism 1 I any, rWtg to UN awe Ice i - Iaed on Was & Enter the .. . t UNDERLYING CAUSE 1 • (tbsewa4jtay seat a 1 insisted the even .. ... .. .. .. .. mum" In death) LAST 1 g 8 • PART IL Older bat not resuf tg In the wwe"awe given in PART L 42L WAS AN AUTOPSY 42b. WERE AUTOPSY FINDINGS AVAMJBa PEFIFO O? TO COMPLETE THE CAUSE OF DEATH w -NO 'Yes, No 43L IF SURGERY MENTIONED IN PART I OR I. ENTER REASON FOR SURGERY 49b. DATE OF SURGERY (Abe, bay, Yrl K DID TOBACCO USE CONTRIBUTE TO DEATH? • -Yw -Pr b" - IAtktornt 4& IF FEMALE, WAS SHE PREGNANT WnNIN THE PAST YEAR: • -Yw XNo - UMnoaa IYsAsPwIlythnesww: - awmadeath _ Within 110 42 days d death -erMtla 43 days to l year of death 46 DATE OF INJURY (Alatth. Day. Yea) 47. TIME OF INJURY (24 fr.) 4& INJURY AT WORK? ala. LOCATION OF IN.IIRY • STATE 7 -Yes _No i • 49b. CRY OR TOWN 49c. STREETADDRESS 4Bd. APT. NO. 498. ZIP CODE 50. DESCRIBE NOW INJURY OCCURRED 51. PLACE OF INJURY (ep: D-WO wales w, N constn m sra, r ~MK wooded area) IF TRANSPORTATION IN.A)RY. SZa" SYaW «Decedent - DtA_,Opaabr - Pa9satger - Pedsselan -Oiwr (,*wily) = o 520.7yfwW ° - Car/Mr&m - S.U.V. _Mobtcyde - PklWTnckfCatga Val - Bas _HeayTmngM - O0w(Sped/y) IMPORTANT INFORMATION - SAVE THIS MAILER Use this section to speed your application for an extension or replacement card (see below). Do Not Bend or Fold This Cut-off Section. A# 012 -843 -192 QUEVEDO, GRISEL 733 WIMBROW DR SEBASTIAN, FL 32958 WELCOME to the BUREAU OF CITIZENSHIP AND IMMIGRATION SERVICES (BCIS) As of Mardi 1. 2003 we are now part of the U. S. Dept. of Homeland Security Why we have reorganized, our function remains the same. This document win remain valid thrmo the expiration date an the front of the card. (Do Not Bend or Fold This Cut-off Section.) FORM I -797D (REV. 3 -1 -00) YOUR APPLICATION HAS BEEN APPROVED. Here is your new card. The expiration date is shown on the front. PLEASE CHECK YOUR CARD TO VERIFY THAT THE INFORMATION ABOUT YOU IS CORRECT H you find an error on it please call us. PLEASE PROTECT YOUR CARD. �^ PLEASE READ THE BACK OF THIS NOTICE. It has important information. We also recommend that you keep this notice for your records. P.O. Box 851488 Mesquite, TX 75185 -1488 INS Texas Service Center Phone Number 1- 800 - 375 - 5283 If you ever have questions about immigration benefits and procedures, or wish to have an application mailed to you, please call our National Customer Service Center at 1- 800 -375 -5283 or check our website at http- /Iwww.ins.usdoj.gov. ;. U.S. Department of Justice Immigration and Naturalization Service Date 11/11/2003 A# 012 -843 -192 Q U E V E D 0, G R I S E L Receipt # SRC0308152402 733 WIMBROW DR SEBASTIAN, FL 32958