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Sep 26 2008 2: 45PM HP LASERJET 3200 p 1
FUNERAL DIRECT R'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENI G IN SEBASTIAN MUNICIPAL CEMETERY
SEt3ASTtqN
hOMI C4'(KU.i3Uwp
For informatior contact:
Ki Kelso -Cemetery Saxton
Se 'astian Mt nicipal Cemetery
1 (772) 559-2545
I
I City Clerk's ()trice
,ty Ha/, 1225 Main Street
Sebastian, FL 32958
Office(772) 388.8215 or 38.3-5'214
Fax: (772) 58S•5570
Fu`ERAL HOME STRUNK IFUNE L HOME ill CREMATORY
1623 yyo.Central Ave.
ADDRESS: SEIBASTiAN, FL 32958
7
PHONE 2)589-1000
(Chalk One)
✓✓ OPEN BURIAL LOT L l _Block 21 Unit Li- 'bed
OPEN CREMAIN'S LOT L I Block Unit 100
.OPEN COLUMBARIUM NICHE Nrhe Block Unit —~"--
•
BURIAL DATE AND SERVICE TIME: I W
l - ;
FOR DECEASED: A ME S_1 eI!`Q Grov.62—
Iva •
•
NAME AND SIGNATURE OF LOT OW ER OR REPRESENTATIVE:
(".,1;A provide pro r documentation or .wnersh•p)
Name �/v tM.. l.� (b I L�✓1
Signature Dnte
I certify tat I have determined the o✓vne ship of the above described site that all site fees and
administrative fees have been paid and authorize opening of same
I
N \1E AND SIGNATURE OF LICENSED FUME, AL DIRE .1' ti - , ,7
� -ham -try) u.r'1�.. 8 8 20�
Name ��
.S' ature Date
Cemetery Sexton Certification:
1 certify that I have checked the ownership inforrration 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 Off.c by Sexton for permanert record upon completion.
Burial Permit Page 1 of 1
State of New Jersey CASE ID NUMBER
BURIAL,CREMATION,OR TRANSIT PERMIT
1450186-REVISED
State law requires that no person shall cremate a dead human body unless at least 24 hours
have elapsed from the time of death listed on death record.
City,Borough or Township Date of Issuance
Mount Holly Township,Burlington County 07/31/2011
The Certificate of Death having been filed with above,as required by the laws of this State,permission is hereby given for the transportation,
removal,burial,cremation,or other final disposition of the body of:
Name of Deceased Age Sex
Agnes S Grover 79 Years Female
Place of Death Date of Death Time of Death
Mount Holly Township,Burlington County 7/28/2011 11:06 AM
•
Cause of Death
•
Proposed Place of Disposition Method of Disposition
Sebastian Cemetery
Sebastian,Florida Burial
Transportation by Common Carrier If Yes,Name of Carrier
Yes Delta Airlines
Name and Address of Funeral Home
Lee Funeral Home
Mt Holly,New Jersey 08060-1405
•
This permit must:be delivered to the superintendent of the cemetery or crematorium where burial;entombment,or cremation is to
take place,who should fill in the spaces below and forward it within ten days to the Registrar of Vital Statistics of the
district in which!the cemetery or crematorium is located.
When burial takes place in a cemetery which has no person in charge,the spaces below should be filled in by the funeral
director,who should write"no person in charge"on the line for Signature of Superintendent of Cemetery orCfematorium and
file the permit with the Registrar of Vital Statistics of the district in which the cemetery is located.The law requires that
this be done within ten days after burial.
r\1 ed GU _
(Name of Deceased).
S ' A.S l h(/ e E� am e ,°
(Date Bun.alorEntomb nt)
at ❑AM ❑PM
(Date and Time of Cremation)
/ naupednfendent Sr tu(` of/ of Cemetery or Crematorium)
PENALTY FOR DISPOSAL WITHOUT PERMIT-$50 TO$100
REG-21X This Burial,Cremation or Transit Permit is electronically produced by NJ-EDRS and can be verified Burial Permit ID
MAY 07 through the EDRS website at 8532881
https://edrs.nj.gov/edrs/burialPerrnitPrintLoad.do 8/1/2011