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SEA
HOME OF PELICAN ISLAND
Certificate No. 1986
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Eleanor Clark 562 Joy Haven Drive, Sebastian, Fl 32958
(name) (address)
in and for consideration of the sum of $700.00 has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plot:
Unit 4 Block 24 Lot 27
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 27th day of August, 2004.
C Y OF SEBA . IAN, FLORIDA
Terrence oore
City Manager
A
y A. Maio, CMC
City Clerk
ON
.O 0
Name 14 lIrld
Unit
Block
Lot
Date of Mark-out
Date of Burial
Name of Funeral Home
Authorized by
Time o
A
CITY OF SEBASTIAN
CITY CLERKS OFFICE
10 1
RECEIPT
Name--,41' Cash
Date— Vhick#--.
No. Amount Paid
001001208001 Sales Tax
001501 3229M Garage Sales
001501341920
Copies/Bid Specs.
001501341910
LDC/Code of Ordinances
001501341930
Election Qualifying Fees
601010 343800
Cemetery Lots
LoVNIche — Block Unit
001501343805 Cemetery Fees
7
Total Paid
White — Dept. of Origin • Yellow — Finance • Pink • Applicant
OY OF
SE
HOME Of PELICAN ISLAND
1225 Main Street, Sebastian, F132958
Telephone (772) 589 -5330 — Fax (772) 589 -5570
August 30, 2004
Ms. Eleanor Clark
562 Joy Haven Drive
Sebastian, FI 32958
Dear Ms. Clark:
Enclosed is City of Sebastian Certificate 1986 for the purchase of Cemetery Lot 27, Block 24,
Unit 4. Also enclosed is a copy of your receipt and the Rules and Regulations governing the
Sebastian Municipal Cemetery.
If you have any questions, please contact our office.
Si erely
Sally A. io, CMC
City Clerk
SAM:ar
enclosure
mor
-w �
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 NaLy-' /eA n0 2
Name(s) . , ` r---, _
Address
— ff. IAX-
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Receipt is acknowledged in the sum of:
Ilars ($ 700. 9" )
on this 41W day of , 20 for the purchase of the following
described Cemetery Lot(s) andj6r Niche(s).
Unit ��" _, Block _, Lot(s) ai 1"2 Niches)
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 /��♦ 5• wed O H
Circle One
Vase and Ring for Niches (cost) Interment
Signature of Pc aser
Disinterment
9d • "—
Service fees are to be paid at time of need only
I: \W W- DATA \Ms - Cemetery\RECEIPT.doc
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CITY OF SEBASTIAN
CITY CLERK'S RECEIPT 3099
3 0 9 9
Total Paid -,
Initia s , ',
White - Dept. of Origin • Yellow - Finance . Pink • Applicant
`
Nam
ash
Date
No.
Amount Paid
001001208001
Sales Tax
001501322900
Garage Sales
001501341920
Copies/Bid Specs.
001501341910
LDCICode of Ordinances
001501341930
Election Qualifying Fees
601010 343800
Cemetery Lots
LotlNlche, Block Unit
001501343805
Cemetery Fees
C9 Roo
nf,-*
tiro,Q
Total Paid -,
Initia s , ',
White - Dept. of Origin • Yellow - Finance . Pink • Applicant
FLORIDA DEPARTMENT OF
HiM:
A. (TYPE)
7
State of Florida, Department of Health, Vital Statistics/
APPLICATION FOR BURIAL - TRANSIT PERMIT �Q QID '
1. Name of First Middle
Last
Date
-V5nthU Day U Year
Deceased MINNIE R.
SINGER
of
AUGUST 23, 2004
Death
2. Place of Death City, Town or Location
Name of (If neither, give street address)
County
Hosp. or
INDIAN RIVER VERO BEACH
Inst. VNA HOSPICE HOUSE
3. Name of Medical
Address
Phone Number
Certifier RICHARD CUNNINGHAM, DO
3800 20TH STREET
772- 794 -2227
Medical Examiner MPh ysician
VERO BEACH, FLORIDA 32960
4. Name of Funeral Home /Direct Disposal
Address
Fla. Lic. No. /Reg. No.
Phone No. (Area Code)
Establishment
735 FLEMING STREET
2617
772- 589 -1033
SEAWINDS FUNERAL HOME
SEBASTIAN,
FLORIDA 32958
5. Check a. U The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. was contacted on
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 within 72 hours.
C. was contacted on He /she verified that
, Medical Examiner, will complete and sign the
medigo certification of cause of death within 72 hours.
S. Funeral Director/ Signature F.E. No. /Reg. No. Date Signed
Direct Disposer 44Z 2294 8/23/04
B. Z BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 04- 2617 -163
A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has
been contacted by the funeral director and will not be able to complete the medical certification of cause -of -death section of the death certificate within
72 hours.
No extension of time for filing the death frttk7quested.
Registrar or Date Date Certificate
Subregistrar Signature Issued: 8/23/04 Due: 8/30/04
C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA
Approval Number: Date
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 _
Method of Disposition: Place of Disposition ---�;��
URIAL
nX CREMATION
Signature of Sexton 1
or Person -in- Charge J)
STORAGE
OTHER (Specify)
Date of Disposition
L24/-
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 County Health Department in the county where disposition occurred.
Distribution: White: Cemetery or Crematory
DH 326, 8197 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
Stock Number 5740 -000- 0326 -2) Pink: Local Registrar