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HomeMy WebLinkAbout4-10-17Name ��Wtir�'�•-. .� -^rn P Unit L/ Block Lot / Date of Mark -out s 21-G7-- - 5— Date of Burial S — 2 Z� Name of Furneral Home Authorized by v Funeral Director's Request to City of Sebastian for Burial Opening in Sebastian Municipal Cemetery Contact Information: City Clerk's Office Cathy Testa City Hall, 1225 Main Street Sebastian, FL 32958 Phone (772) 388-8209 ctesta(aa)citvofsebastian.ore Thn Un`J` Funeral Home:_f k a " (&'r`_ S"' ( on - Address: �� 5 \V� v"jclty ✓i1r/`QQ� e--aCX.G#'i7 70. ✓`gam 4 PhoneZ (Check Open Burial Lot J_L_ Open Cremains Lot F_ Open Columbarium Niche ' Burial Date and Service Time: 5Ia*l S Unit Block 10 Lot % 3- Ullit_ Block Lot Unit_ Block_ Niche_ Deceased Name: Name and Signature of Lot Owner or Representative: (Must provide proper documentation of ownership) Print Name Signature Date 3 (P Ref6vt cak 0-34F-� Address.:5,h,h,, 3ZIS8 Pho cNu ber I certify that I have determined the ownership of the above -described site that all site fees and administrative fees have been paid and authorized opening of same. Name and Signature of Licensed Funeral Director: `� Winn..rc_ 5 9�2r not Name Signature Date 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 Certification: C mete .. --�- 'f— Dat This form is to be provided to Clerk's Office for permanent record upon completion. CITY OF SEBASTIAN 17017 FINANCE DEPARTMENT RECEIPT I Name Cash Date Check#�l3_�`t6-6' ❑ Credits Amount Paid 001501 362150 Non -Taxable Rent 001001 220000 Security Deposit 001501 362100 Taxable Rent 001001 208001 Sales Tax 450010 369900 Airport Badge 450010 362521 AP Shade Hangar Rent 450001 208045 Airport Sales Tax 001501 347557 Community Center Revenue 001501 341920 General Fund Copies 001501 354100 Code Enforcement Fines 601010 343800 Cemetery Lot Sales 001501 343805 --�� Cemetery Fees 480010 341920 Bldg Dept Copies PD Shop with a Cop PD COPE PD Cadets PDSRTT ,A0— 1-1 J� Initials White - Dept. of Origin Total Paid U Yellow - Finance Doi. • Pink - Applicant State of Florida, Department of Health, Bureau of Vital Statistics BURIAL TRANSIT PERMIT 14 TH DATE PRINTED: May 20, 2025 TRACKING NUMBER: 2025095013 1. DECEDENT INFORMATION Name of Deceased Date of Death TIMOTHY JAMES RAINES May 16, 2025 Place of Death - County City, Town or Location Name of facility, or street address if not a facility MANATEE BRADENTON MANATEE MEMORIAL HOSPITAL Name and Address of Funeral Home/Direct Disposal Establishment Fla. Lie. No./Reg. No. Phone Number SEAWINDS FUNERAL HOME F073380 F073380 (772) 589-1933 735 SOUTH FLEMING STREET SEBASTIAN, FLORIDA, 32958 Funeral DirectodDirect Disposer Fla. Lic. NodReg. No. TARA A. STANLEY F022899 Medical Verification Statement Hospice at the certifying physician's office, was contacted on 05/1912025 by the funeral director listed above; he/she indicated that SUSAN JOY DRUKMAN, certifying physician, will complete and sign the medical certification of cause of death within 72 hours. 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: 2025-FO73380-5104 Date Issued: May 19, 2025 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, 10112 64V-1.011. Florida Administrative Code CITY OF R ~ n e ~~ i ~IM~~~~~ rte. HOME OF PELICAN ISLAND Certificate No. 2183 Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Laverne Raines 36 Treasure Circle, Sebastian, FL 32958 (name) (address) In and for consideration of the sum of $2,000.00 is entitled to full interment rights in the Sebastian Municipal Cemetery for the following lots: Unit 4 Block 10 Lots 17 & 18 of the Sebastian Municipal Cemetery, as maintained on file in the records of the City Clerk for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. CONVEYED THIS 10th day of June, 2008. CITY fJF S,~~3ASTIAN, FLORIDA AI Minner ty Manager ATTEST: - Sally A~ City tl -'j~ ~~ ~~ ~ ~ Maio, MMC Clerk clot ~ S~,BASTI~j ~~ HOME Of PELICAN ISLAND ~ ~~ City of Sebastian Municipal Cemetery Purchase Receipt To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate regulations, residence of purchaser or person for whom lot is intended for interment must be provided at time of purchase Name(s) .~~~ ~"~-P.cz~~a ~~ Ci rc~~, 5e-~a~5frc~.h ~~ 3Z~5$ Address Area Code & Phone Nu ~" es r n es Residence Address of I ended Occupant if er Than Purchaser Office Use Only Receipt is acknowledged in the sum of: ~,1~ ~~1,6-(,L,Q,~y1/1,G~ Q.VCD~ ~~D~O Dollars ($ ~C~ C~ 0 J QU ) on this ~ ~~f~ day of ~(~h ~ ~ , 20~ for the purchase of the following described Cemetery Lot(s) and/or Niche(s). Unit ~ ,Block C 0 ,Lot(s) 17 `~' l ~ 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 W O H Circle One Disinterment TOTAL $ oZl JrD ~ Q (~ Signature of Purchaser W . ' y of Sebastian Service fees are to be paid at time of need only ~~"D . pU I:\W W-DATA\Ms-Cemetery\RECEI PT.doc CITY OF SEBASTIAN CITY C RECE' pOFFICE ~ [) ~ n Name / C~o~ n l ".. - ~ ^ Cash / Date (~J " / ~ 1 CO ' C~~ Check # ~ R~9 No. Amount Paid 001001 208001 Sales Tax 001501322900 Garage Sales 001501341920 CopieslBid Specs. 001501341910 LDC/Code of Ordinances 001501 341930 Elecfion Qualifying Fees /~/~ U 601010343800 Cemetery Lots ~ ~/ ~ o ~ ~ ~ ~ t , Block L UNi e ,Uni !l ~I© 001501 343805 Cemetery Fees ~/ . /~ ' Total Paid ~ ~ ~~ ~ ~ Initials White -Dept. of Origin • Yellow -Finance • Pink • Applicant CITY M Sfj3ASTI Atj HOME OF PELICAN ISLAND Burial rights in the Sebastian Municipal Cemetery Address and one I y 1 1 Unit Block Intended for interment of the following individual(s): Please print name(s): grit*� �,ru s CC-Weaxe A iz'A3 I have read and understand the terms of this agreement. Signature STATE OF FLORI4A COUNTY OF M Dale l'Tlz The fore22ing instrument was cknowled ed before me by means of ( ) ph al presence or ( ) online notarization this _day of NVl 2,E, by r-AIQP/'!� �O who is personally known to me, or has produced as identification. Notary ubfic, State of Flon a 3 ? My Cnt,M.,fISSION EXPInL ,;-27.2026 E CITY OF SEBASTIAN 17017 FINANCE DEPARTMENT RECEIPT I Name Cash Date Check#�l3_�`t6-6' ❑ Credits Amount Paid 001501 362150 Non -Taxable Rent 001001 220000 Security Deposit 001501 362100 Taxable Rent 001001 208001 Sales Tax 450010 369900 Airport Badge 450010 362521 AP Shade Hangar Rent 450001 208045 Airport Sales Tax 001501 347557 Community Center Revenue 001501 341920 General Fund Copies 001501 354100 Code Enforcement Fines 601010 343800 Cemetery Lot Sales 001501 343805 --�� Cemetery Fees 480010 341920 Bldg Dept Copies PD Shop with a Cop PD COPE PD Cadets PDSRTT ,A0— 1-1 J� Initials White - Dept. of Origin Total Paid U Yellow - Finance Doi. • Pink - Applicant State of Florida, Department of Health, Bureau of Vital Statistics BURIAL TRANSIT PERMIT 14 TH DATE PRINTED: May 20, 2025 TRACKING NUMBER: 2025095013 1. DECEDENT INFORMATION Name of Deceased Date of Death TIMOTHY JAMES RAINES May 16, 2025 Place of Death - County City, Town or Location Name of facility, or street address if not a facility MANATEE BRADENTON MANATEE MEMORIAL HOSPITAL Name and Address of Funeral Home/Direct Disposal Establishment Fla. Lie. No./Reg. No. Phone Number SEAWINDS FUNERAL HOME F073380 F073380 (772) 589-1933 735 SOUTH FLEMING STREET SEBASTIAN, FLORIDA, 32958 Funeral DirectodDirect Disposer Fla. Lic. NodReg. No. TARA A. STANLEY F022899 Medical Verification Statement Hospice at the certifying physician's office, was contacted on 05/1912025 by the funeral director listed above; he/she indicated that SUSAN JOY DRUKMAN, certifying physician, will complete and sign the medical certification of cause of death within 72 hours. 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: 2025-FO73380-5104 Date Issued: May 19, 2025 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, 10112 64V-1.011. Florida Administrative Code