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Home My WebLink About4-25-25Name Unit .s Block Lot Date of Mark-out— Date of Burial Name of Funeral Ho Authorized by--� el /-C/ _ (F_ iia✓! aim /��-° S . je Time CITY OF SEBASTIAN 10931 c.A_DMINISTR/ATIVE SERVICES RECEIPT NameVtKi uAl� I flf VEIZ kV a Cash Date Io I 11 117 check#'7734- ❑ Credit Amount Paid 001001 208001 Sales Tax 001001 220000 Security Deposit 001501 362100 Taxable Rent 001501 362150 Non -Taxable Rent 450010 369900 Airport Badge 001001 218010 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 �ct�0l '343-139c)-.5, DIC_ 4 SC . Untir 4 611<aS taras LIP Initials Total Paid' ��• oU White - Dept. of Origin • Yellow - Admin. Svcs. • Pink -Applicant FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY For information contact: Kip Kelso, Cemetery Sexton X00 Sebastian Municipal Cemetery A Phone: (772) 589-2545 Fax: (772) 228-9927 City Clerk's Office – Cathy Testa 1�\�\ City Hall, 1225 Main Street Sebastian, FL 32958 Office (772) 388-8215 or 388-8214 ctesta(a)cifyofsebastian.org FUNERAL HOME: Strunk Funeral Home and Crematory ADDRESS: 1623 North Central Avenue, Sebastian, Florida, 32958 PHONE#: 772 -589 - (Check One) XXXXXOPEN BURIAL LOT OPEN CREMAINS LOT OPEN COLUMBARIUM NICHE BURIAL DATE AND SERVICE TIME Lot-25—Block 25 Unit 4 Lot—Block—Unit Niche Block Unit N S E W Will call DROP-IN FOR DECEASED: William Foster Haverlev Name NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership) Darla M. Haverlev Aarl,a M. Ff2Verleo 10/11/2017 Name Signature Date 119 Kildare Drive, Sebastian, Florida, 32958 1 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: Tim Marvin Name Twt M=u Signature 10/11/2017 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. FUNERAL DIRECTOR'S REQUEST TO cify OF S STIAN FOR BURIAL OPEN NG IN SEBASTIAN MUNICIPALCII MUNICIPAL METERY For information contact p Kelso, . Cemetery SeA ton Sebastian Municipal Comi t 3ry Phone: (772) 589.254 Fax: (772) 228-9927 Cifj Clerk's Office — Cathy T 2sta ity Hall, 9225 Main Stri le t Sebastian, FL, 32958 Office (772) 388-8215 or 388.8214 ctesta iii.-Wofsebalat4n.ong FUNERAL HOME: Strunk Funeral Home and crematary ADDRESS: 1623 North Central Avenue, Sebastian, Florida, 3295 PHONE* 772-589-1000 (Check One) XXXXXOPEN BURIAL LOT Lot_25_Bla i 4-Unit- 5UnitOPEN OPENCREMAINS LOT Lot Block Unk OPEN COLUMBARIUM NICHE Niche Ick nit BURIAL DATE AND SERVICE TIME: Wednesday,l0/18/2017 11:30 AM N 2 will complete comm FOR DECEASED: William Foster Haverley Name NAME AND SIGNATURE OF LOT OWNE R OR REPRESENTATI : (Must provide proper documentation of ov fnership) Darla M. Havedgy Signature /11/2017 ate Name 119 Kildare Drive, Sebastian, Florida, 32958 1 certify that I have determined the ownere hip of the above describe site that a iie fees and administr fees have been paid and authorize openir g of some. NAME AND SIGNATURE OF LICENSED FUNERAL DIRECTOR: Tim Marvin TIt Jv=K Signature 1 /11/2017 Name ate Cemetery Sexton Certification: 1 certify that I have checked the ownership information by viewing t1/0/ wner's d and confirming with office and that all fees ave been paid: ;_1 /,q// 8 Ce to Sexton Date This form to be provided to Clerk's Office by Sexton for permanent E cord upon cc pletion. ittal (13/1) stive Clerk's State of Florida, Department of Health, Bureau of Vital Statistics O r 173BURIAL TRANSIT PERMIT HFALI-H DATE PRINTED: October 11, 2017 TRACKING NUMBER: 2017160385 1. DECEDENT INFORMATION Name of Deceased Date of Death WILLIAM FOSTER HAVERLEY October 7, 2017 Place of Death - County City, Town or Location Name of facility, or street address if not a facility INDIAN RIVER VERO BEACH VNA HOSPICE HOUSE Name and Address of Funeral Home/Direct Disposal Establishment Fla. Lic. No./Reg. No. Phone Number STRUNK FUNERAL HOME- SEBASTIAN F041870 F041870 (772) 589-1000 1623 N CENTRAL AVE SEBASTIAN, FLORIDA, 32958 Funeral DlrectorlDirect Disposer Fla. Lic. No./Reg. No. TIMOTHY W. MARVIN F022789 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: 2017-FO41870-5169 Date Issued: October 9, 2017 State Registrar 3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL -AT -SEA, or HOSPITAL DISPOSITION Authorization given by Medical Examiner District 19 Approval Number: C17-19-10-166 4. CEMETERY OR CREMATORY Place of Disposition: VERO BEACH CREMATORY Method of Disposition: CREMATION 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 10/11/2017 10:23 7!7127 P.001/001 FUNERAL DIRECT R'S REQUEST TO C11 TY OF SEE JTIAN FOR BURIAL OPEN114G IN SEBASTIAN M ICIPAL CE ETERY For information contact: Kip Kelso, .Cemetery Se Sel astian Municipal Come Phone. (772) 589-2545 Fax: (772) 228-9927 City Clark's Office ^- Cathy Testa ity Hall, 1225 Main Stye Sebastian, FL 32958 Office (772) 388-8215 ar 388-8214 ctes a Otvofsebastig or FUNERAL HOME: Strunk Funeral Ho Tie and Crennatory 2bastian, Florida, 32958 ADDRESS: 1623 North Central Avenue, S PHONE#: 772-589-1000 (Check One) XXXXXOPEN BURIAL LAT Lot-25—Bloc 25 Unit OPEN CREMAIN$ LOT t_ot_Slock Unit OPEN COLUMBARIUM NICHE Niche -B k it BURIAL DATE AND SERVICE TIME: Will call DROP-IN FOR DECEASED: Name NAME AND SIGNATUREOF LOT OWNFf t OR REPRESFNTATIV : (Must provide proper documentation of owT iership) Darla M. Haver[ey if 11/2017 Name Signature Elote 119 Kildare Drive, Sebastian, Flprida, 32958 1 certify that I have determined the owners ip of the above describec Site that all si fees and administn fees have been paid and authorize openinc of same. NAME AND SIGNATURE 'OF LICENSER i UNERAL DIRECTOR: Tim Marvin TMMoattiK Signature 1 I fl /2017 ate Name Cemetery Sexton Certification: I certify that I have checked the ownership office and that all fees have been paid: nformation by viewing th wner's cle ac and confirming with /D / / Cemet ry 8 0n Date This form to be provided tr 4 lek's Office b Sexton for permanent r ord upon t ol III pletion. 3tive Clerk's Tttu of Orhastian 0 , r to iG t r r y jj r r 0 NO. 1'_•-I" 15th November 96 THIS INDENTURE MADE This day of ............................................. A. D, 18......, between the City of Sebastian, a municipal corporation existing under the laws of the State of Florida, as Grantor and Bill and/or Darla Haverley ...........................................119' Kii-d:are'DriVe............................................................. ...........................................Sebastian,.. .................Florida 3295.................................................. of the County of .Indian Ri............. ver .......... ani State of ...... Flox;.da.................................... as Grantee, WITNESSETHe That the Grantor for and in consideration of the sum of $ ....1.45 90_.00 ......... to it in hand paid, the receipt whereof is herewith ac- knowledged, does by this instrument grant, bargain, sell, release, convey and confirm unto the Grantee . ,their heirs, legal representatives and assigns the following pr r y situated 5 n Sebastian, Indian River County, Florida, to -wit: All of Lot(s) 1, . 25 9 ,Block26 , . 2 5.... ,UNIT ,4, .......... , of Sebastian municipal cemetery as per Plat Number 1 thereof recorded in Plat Book 2, at page 65 of the public records in the office of the Clerk of the Circuit Court of St. Lucie County of Florida; said land now lying and being in Indian River County, Florida. To Have and to Hold the same forever; provided that said property shall be used solely and exclusively for the interment of the human dead and shall be used, kept and maintained at all times in accordance with the rules and regulations, ordinances and resolutions of the City of Sebastian, Florida, hereto- fore, now and hereafter adopted or provided for the government and operation of said cemetery. The conditions, restrictions and requirements contained in this instrument shall be covenants running with the land. In the event of the failure of the owner of any property situated within said cemetery to ob- serve and comply with such rules, regulations, resolutions and ordinances and the conditions of the dried of conveyance thereof then the title of such owner in and to said property shall terminate and the same shall revert to the City of Sebastian, Florida. IN WITNESS WHEREOF, The said party of the first part has caused this instrument to be executed in its name and on its behalf by its Mayor and attested by its City Clerk and its corporate seal to be hereto affixed, the day and year first above written. Attest... .M..D 4&4.4 J ... City Cleric Signed, Sealed and Delivered in the Presence of: TATE OF FLORIDA COUNTY OF INDIAN RIVER CITY OF SEBASTIAN, FLORIDA By6+.4a�. %e . . Mayor ((fflta "seal) I HEREBY CERTIFY, That on this .......15th ..........day of ...... Nove.Iilber................................ la9b., d before me personally appeared .Louise R. Cartwright Kathr n M. O'Hallo.ran ......................................................... an ......... Y.............,,...,.ran. respectively Mayor and City Clerk of the City of Sebastian, a municipal corporation under the laws of the State of Florida to me known to be the individuals and officers described in and who executed the foregoing conveyance to Bill and/or, Darla,,Haverley................................................ ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, and severally acknowledged the execution thereof to be their free act and deed as such officers thereunto duly authorized; and that the Official seal of said corporation Is duly affixed thereto, and the said conveyance is the act and deed of said corporation. /� 1 i Name Unit Block Lot Date of Mark -out Time Date of Burial Name of Funeral Home.' Authorzed-by QState of Florida, Departt of Health and Rehabilitative Services, Vi tistics 5 APPLICN FOR BURIAL —TRANSIT PERMIT ��` A. (Type or Print) Z// 1. Name of First Middle Last DATE Month Day Year Deceased OF Brandi Rae Haverley DEATH 10/15/96 2. Place of Death City, Town or Location Name of (If neither, give street address) County Hosp. or Inst. 3. Name of Medical X Medical Examiner Address Phone Number Certifier 2`500 S. 35th Street Physician 4. Name of Funeral Home/ Address Fla. Lic. No./Reg. No. Phone Number (Area Code) Direct Disposer I 1623 North Central Avenue 5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies Appro- this application. priate Box b ❑ was contacted on within 72 hours after death. He/she verified that this death was from natural causes, that there .was no accident nor other external cause of death, and that will complete and sign the medical certification of cause of death. c Hwl en was contacted oni n/1 Z, f qB . He/she verified that Frederick Hobin, M.D. , M.E. Medical Examiner, will complete and sign the medical certification. 6. Place of Sebastian Cemetery instate cemeter Removal Final Disposition: atory - ounty: Indian River from state Donation 7. Funeral Director/ I natur F.E. No./Reg. No. Date Signed �* -4642 1 Sr 4L Z 10/17/96 B. LBURIAL - TRANSIT PERMIT 1228-96-0477 Permission is hereby granted to dispose of this body. Permit No. ❑ A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted as undue hardship would result from filing within the normal time limit. If the certificate cannot be filed within this extended time limit, a "Funeral Director/Direct Disposer Report" will be filed with the Local Registrar of the County in which death occurred. ❑ No extension of time for filing the death certificate requested. 'Reyebtidl Date / / Date Certificate_ / Subregistrar Signature r M Issued: /D / S/ 9 �. Due: 9G C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL-AT—SEA Signature Medical Examiner Date or Medical Examiner, gave authorization by telephone to _ Funeral Director/Direct Disposer. . Date The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting period of.48 hours after death is required for all cremations. D. CEMETERY OR CREMATORY Methods of Disposition: Place of Disposition Sebastian Cemetery ® BURIAL ❑ STORAGE Date of Disposition nt-t.n}ap_r 90 - 1 496 ❑ CREMATION ❑ OTHER (Specify) Signature of Sexton ) or Person -in -Charge) 404 ' This permit must be endorsed by the Sexton or person -in -charge (or by the Funeral Director/Direct Disposer when there is no Sexton) and returned within 10 days to the local HRS County Public Health Unit in the County where disposition occurred. HRS Form 326. Feb 89 (Replaces Oct 87 edition which may be used) (Stock Number: 5740-000-0326-2) I