Loading...
HomeMy WebLinkAbout4-10-07FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY 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: Strunk Funeral Home and Cremato ADDRESS: 1623 North Central Avenue, Sebastian, Florida, 32958 PHONE#: 772-589-1000 (Check One) XXXX OPEN BURIAL LOT Lot-7—Block 10—Unit 4 MARKER SOLD OPEN CREMAINS LOT Lot—Block—Unit OPEN COLUMBARIUM NICHE Niche Block Unit N S E W 12:00 NOON, Saturday, 10/29/2016 - Prayer Service - CHAPEL BURIAL DATE AND SERVICE TIME: FOR DECEASED: Guerrino Pedini Name NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership) Lucia Pedini Iwo Tedw 10/27/2016 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: Gary D. Evans Name QOhtq CD. PVOdS 10/27/2016 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: Cemetery Sexton Date This form to be provided to Clerk's Office by Sexton for permanent record upon completion. 10/27/2016 14:00 FUN�RAL DIRECTOR'S RBOUEST TO FOR BURIAL OPENING IN SEBASTIAN I NAME AND SIGNATUR� OF LOT OWNER OR RI (Must provide proper do umentation of ownership) OF Name Signature I certify that I have deter nined the ownership of the above describ site that all s fees have been paid anc authorize opening of same. NAME AND SIGNATUR 1 OF LICENSED FUNERAL DIRECTOR: Gary D. Evans Name Cemetery Sexton Cert I certify that I have the office and that all fees Signature the ownership infonnation by viewing been paid: 0 owner's This form to be provided1to Clerk's Office by Sexton for permanent r4cord upon #6100 P.001/001 4ARKER SOL[ nit feq Service - CHAPEL 10/2712016 Date e fees and administrative 10/27/2016 Date and confirming with Clerk's ipletion. For information contact: Kip Kelso.Cometery Sean Sebastian Municipal Come (772) 589-2545 City Clerk's Office City Hall, 1225 Main Stye Sebastian, FL 32958 Office (772) 388-8215 or 384 Fax: (772) 589-5570 FUNERAL HOME: Stri ink Funeral Home and Crematory ADDRESS: 1623 North entral Avenue. Sebastian. Florida. 3295E PHONE#: 772-589-1030 (Check One) XXXX OPEN BURIAL LOT Lot„7_Block 10_ OPEN CREMAIN 3 LOT Lot- OPEN COLUMB RIUM NICHE Niche N S 12:00 NOON, Saturday, l( BURIAL DATE AND SERVICE TIME: FOR DECEASED: Gu rrino Pedini NAME AND SIGNATUR� OF LOT OWNER OR RI (Must provide proper do umentation of ownership) OF Name Signature I certify that I have deter nined the ownership of the above describ site that all s fees have been paid anc authorize opening of same. NAME AND SIGNATUR 1 OF LICENSED FUNERAL DIRECTOR: Gary D. Evans Name Cemetery Sexton Cert I certify that I have the office and that all fees Signature the ownership infonnation by viewing been paid: 0 owner's This form to be provided1to Clerk's Office by Sexton for permanent r4cord upon #6100 P.001/001 4ARKER SOL[ nit feq Service - CHAPEL 10/2712016 Date e fees and administrative 10/27/2016 Date and confirming with Clerk's ipletion. State of Florida, Department of Health, Bureau of Vital Statistics -- — BURIAL TRANSIT PERMIT HEALTH DATE PRINTED: October 27, 2016 TRACKING NUMBER: 2016166391 1. DECEDENT INFORMATION Name of Deceased Date of Death GUERRINO PEDINI October 27, 2016 Place of Death - County City, Town or Location Name of facility, or street address If not a facility INDIAN RIVER VERO BEACH INDIAN RIVER MEDICAL CENTER Name and Address of Funeral HomelDirect Disposal Establishment Fla. Lie. No.IReg. No. Phone Number STRUNK FUNERAL HOME- SEBASTIAN F041870 F041870 (772) 589-1000 1623 N CENTRAL AVE SEBASTIAN, FLORIDA, 32958 Funeral Director/Direct Disposer Fla. Lie. No./Reg. No. GARY D. EVANS F055074 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: 2016-FO41870-5183 Date Issued: October 27, 2016 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 CITY OF SEBASTIAN 10392 ADMINISTRATIVE SERVICES RECEIPT Name STRu�DInt i ❑Cash Date b;Check # Ll Credit Amount Paid 001001 208001 Sales Tax 001001 220000 Security Deposit 001501 362100' Taxable Rent 001501 362150 Non -Taxable Rent 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 329200 Site Plan Review 001501 329300 Subdivision/Plat Review 001501 329100 Zoning Fees bofsat - 34-32o5' ya,T 4 &4 icLar r7 ZA Total Paid� � �� Init Security Dep Held - Amount $ Check # White - Dept. of Origin • Yellow - Admin. Svcs. • Pink - Applicant Name LL G �� �/1rD ��� //� 7�C /25 /ties Unit Block Lot Date of Mark -out Date of Burial /U 4! / —Time G Name of Funeral Ho Authorized by CRY OF ~~~~~ ~...:: HOME OF PELICAN ISLAND Certificate No. 2168 ~~ ~~ ~~ Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Guerrino 8~/or Lucia Pedini 418 Maple Street, Sebastian, FL 32958 (name) (address) In and for consideration of the sum of $2,000.00 is entitled to full interment rights in the Sebastian Municipal Cemetery for the following lots: Unit_4_Block_10_Lots_7 & 8_ of the Sebastian Municipal Cemetery, as maintained on file in the records of the City Clerk for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. CONVEYED THIS 7t" day of March, 2008. F SEBASTIAN, FLORIDA ATT T: ~~~ AI Minner Sally .Maio, MMC City Manager City Clerk cm ~ ~I ,~ ~._ ~ r ~~ HOME Of PE4iUN ISWVD • ~~ City of Sebastian Municipal Cemetery Purchase Receipt ~,e.rr~~~ o To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate regulations, residence of purchaser or person for whom lot is intended for interment must be provided at time of purchase Names ~ ( ~~-~/ f e. S tie ~,f- `~bat5 i~~ ~ r/ 3 z 4 S ~ Address ~77~ 38"t-9'~-7 Area Code & Phone Number Residence Address of Intended Occupant if Other Than Purchaser Office Use Only Receipt is acknowledged in the sum of: Gl.!/l.~ ~%~J"D ~J ~ tars ($ OOd , ~~ ) on this ~ ~ day of ~GI,Y , 20~ 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 Signature of Purchaser W O H Circle One Disinterment TOTAL $ / i, , of Sebastian IN Service fees are to be paid at time of need only I:\W W-DATA\Ms-Cemetery\RECEI PT.doc CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT ~ 9 C / U Name t~C [.. ~1 t n ~ ^ Cash Date ~ ' - I ~ QO ^ Check# No. Amount Paid 001001 208001 Sales Tax 001501 322900 Garage Sales 001501 341920 CopieslBid Specs. 001501341910 LDCICode of Ordinances 001501 341930 Election Qualifying Fees ~ ~ 601010343800 Cemetery Lots ~j LoUNiche ~, Block r ~ ,Unit 001501 343805 Cemetery Fees Total Paid t:~~ Initials White - De f Origin • Yellow -Finance • Pink • Applicant UCIA P PEDINI 567 GARY PEDINI 418 Maple St ss-sasis~o r Sebastian, FI, 329 -4348 ewwc +oosas ~ _ ~y ~ - Date Pay to the order of ~ ; ~ D©~ 4 F7.Y':; Dollars a ~~k"t LJ -~ WACHOVIA Be„efztBankin 8 chovia'Bank, N.A. w ftovia.com ' c For ~ M, x:0 6 7006 4 3 2~: 10900 L 478395ii' 0567