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HomeMy WebLinkAbout4-22-100 ayyOF SERAS11AN HOME OF PELICAN ISLAND Certificate # 1931 CI T YUSEBASTIANI Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Kathryn & George Westerfield 291 Faith Terrace, Sebastian, F1 32958 (name) (name) (address) (address) in and for consideration of the sum of $ 7 0 0.0 0 , has purchased and is entitled to full interment rights in the Sebastian Municipal Cemetery for the following plot: Unit 4 , Block 2 2 , Lot(s) 10 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 4th day o f December 12004 CITY OF SE ASTIAN, FLORIDA Terrence R. Nroore City Manager ATTEST: Sally A. aio, CMC City Clerk o / ` Name Unit Block 04— Date Of Mark-out -:Z Date Of Burial Time Name of Funeral Authorized by cr) a I ce It I` ❑ iv 0 N O. A o 1 s O ie 64 i i f 1 A c cc O W W M W H 33:� � dQ�WLL, z - t- ; �U_ QF 0 Ln U. 5C CW7 0. °� wo No. 001001 208001 001501 322900 001501 341920 001501 341910 001501 341930 601010 343800 001501 343805 CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT Sales Tax Garage Sales Copies/Bid Specs. LDC /Code of Ordinances Election Qualifying Fees 2361 0 Cash eck 7 7 Amount Paid Cemetery Lots' © D a Lot/Niche Block c" Unit Cemetery Fees AS C)0 Total Paid Initials White - Dept. of Origin • Yellow - Finance • Pink - Applicant a rn I` ❑ N O. o 1 s O ie o IYt No. 001001 208001 001501 322900 001501 341920 001501 341910 001501 341930 601010 343800 001501 343805 CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT Sales Tax Garage Sales Copies/Bid Specs. LDC /Code of Ordinances Election Qualifying Fees 2361 0 Cash eck 7 7 Amount Paid Cemetery Lots' © D a Lot/Niche Block c" Unit Cemetery Fees AS C)0 Total Paid Initials White - Dept. of Origin • Yellow - Finance • Pink - Applicant alror SEBASTKN 1731 1 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 Nam6(s) / Address 772 - _5-25'1- o��6 Area Code & Phone Number Residence Address of Intended Occupant if Other Than Purchaser Office Use Only Rece' is acknowledged in the sum of: on this descrit day of , 20 4t3 Cemetery Lot(s) and /or Niche(s). Unit , rs ($,';��d , d ) for the purchase of the following 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 / -S� L d O H Circle One Vase and Ring for Niches (cost) Interment Disinterment Signature of Purchaser of Sebastian Service fees are to be paid at time of need only 1: \W W- DATA\Ms- Cemetery\RECEIPT.doc December 5, 2003 Kathryn & George Westerfield 291 Faith Terrace Sebastian, F132958 Dear Mr. & Mrs. Westerfield: Enclosed is City of Sebastian Certificate Number 1931 for the purchase of Cemetery Lot 10, Block 22, 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. S' er ly, Sally A. taio, CMC City Clerk SAM:ar enclosure FLORIDA DEPARTMENT OF ,(�� _ �� Q HEALT State of Florida, Department of Health, Vital Statistics / APPLICATION FOR BURIAL - TRANSIT PERMIT A. (TYPE) 1. Name of First Middle Last Date Month Day Year Deceased of Mary Hoehl Death Dec- 3 2003 2. Place of Death City, Town or Location Name of (If neither, give street address) County Hosp. or Indian River Roseland Inst. Sebastian River Medical Center 3. Name of Medical Address Phone Number Certifier Nasir Rizwi, M.D. 13885 U.S. #1 Medical Examiner Physician Sebastian, FL 772 - 589 -6844 3. Name of Funeral Home /Direct Disposal Address Fla. Lic. No. /Reg. No. Phone No. (Area Code) Establishment 1623 N. Central Ave. Strunk Funeral Home Sebastian, FL 1228 772 - 589 -1000 i. Check a. The medical certification has been completed and signed. A completed certificate of death accompanies this Appropriate application. Box b• E Jennifer was contacted on 12/3/03 He /she verified that this death was from natural causes, that there was no accident nor other external cause of death, and that Dr. Rizwi 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 me cal certificat' of cause of death within 72 hours. i. Funeral Director/ S' a F.E. No. /Reg. No. Date Signed Direct Disposer 1862 12/3/03 ;. BURIAL - TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No. 1228 -03 -0490 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 certificate has been requested. Ra@ ctrar or Date Date Certificate Subregistrar Signature — Issued: 12/3/03 Due: 12/8/03 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. Method of Disposition: bBURIAL CREMATION Signature of Sexton or Person -in- Charge STORAGE OTHER' (Specify) CEMETERY OR CREMATORY Place of Disposition Sebastian Cemetery Date of Disposition ��/ O 8 /0 3 , his permit must be endorsed by the Sexton or person -in- charge (or by the Funeral Director /Direct Disposer whemijbwe ' j&fts P.e, returned ithin 10 days to the local County Health Department in the county where disposition occurred. �l �� �� Y�/W � Distribution: White: Cem r 1 326, 8/ Obsoletes all previous editions) Yellow: Funere ector ct tock Number 5740- 000 - 0326 -2) Pink: Local Registrar