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Home My WebLink About4-16-07�o �� s��T�►� ,-.:�. �:..�....� HOME OF PEUUN ISWVD � 0 � Certificate # 1938 �� _ �� )�' ��_ �� Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Fortunato and Sandra Roma (name) 433 Memorial Ave., Sebastian, Fl 32958 (address) in and for consideration of the sum of 1 400.00 has purchased and is entitled to full interment rights in the Sebastian Municipal Cemetery for the following plot: Unit _ 4_, Block 16 , Lot(s)_7 & 8_ of the Sebastian Municipal Cemetery, as maintained on �le 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 OF City Manager 14`h day of January, 2004. �p, TEST: .- , � � � - �� " � Sall A. Maio, CMC City Clerk 0 I�O 0 [� . Name �Q �! V��J 1 C7 � � M r7 Y X��/ �� l�s Unit `�� B�o�k J 6 �at 7 Date of Mark-out f�� r �� Date of Burial 1�'�� -f Time �� O /�. � ' Name of Funeral,Wome � .�f �U'v Authorized s a FLORIDA DEPARTMENT OF HEALT Name of Deceased :. Place of Death County - 1 ndian Ri�;:� State of Florida, Department of Health, Vital Statistics APPLICATION FOR BURIAL - TRANSIT PERMIT First Fortunato Middle Last City, Town or Location Vero Beach Roma Name of Hosp. or Inst. Date of Death (If neither, give street address) / ' � D Indian River Memorial . Name of Medical Address certitier Seth Baker, D. . 7955 Bay Street Medical Examiner Physician Sebastian, F�. . Name of Funeral Home/Direet-Biepesa�f— Address Establishment 1623 N Central Ave Check a. u Appropriate Box b. �I c. � Funeral Directod Month Day Year Jan. 10 2004 Phone Numb�r 772-388-4606 Fla. Lic. No./Reg. No. � Phone No. (Area Code) ' 1228 772-589-1000 The medical certification has been completed and signed. A completed certificate of death accompanies this application. Sharon was contacted on 1/12/04 He/she verified that this death was from natural c9uses, that there was no accident nor other extemal cause of death, and that Dr. Baker will complete and sign the medical certification of cause of death within 72 hours. was contacted on . He/she verified that , Medical Examiner, will complete and sign the of death within 72 hours. % F.E. No./Reg. No. 862 BURIAL - TRANSIT PERMIT Date Signed 1/10/0� Permission is hereby granted to dispose of this body. Permit No. 122$-04-0021 �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. R�� Date Date Certificate Subregistrar Signature �-�„L',c'jb„ /L1 e_d,�„ Q�( Issued: �� 0� Due: 1/ 15 /04 AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT SEA Approval Number: Date Medical Examiner, , gave authorization by telephone to Funeral DirectodDirect 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. CEMETERY OR CREMATORY Me hod of Disposition: Place of Disposition Sebastian Cemetery BURIAL � STORAGE Date of Disposition /// y��' �CREMATION Signature of Sexton � or Person-in-Charge � OTHER (Specify) 0 �is 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 thin 10 days to the local County Health Department in the counry where disposition occurred. 326, 8/97 (Obsoletes all previous editbns) Distrfbution: Whtte: Cemete or Cremetory p �ck Number: 5740.000-0326-2) Yellow: Funere� irector or Direct Dis oser Pink: Local R fshar CITY OF SEBASTIAN CITY CLERK'S OPFICE 2 4 5 3 RECEIPT ' Name ❑ Ca:h Date eck ��j��T,.j No. Amount Pafd 001001 208001 Sales Tax 001501 322900 Garage Sales 001501 341920 CopieslBid Specs. 001501341910 LDC/Code of Ordinances 001501 341930 Eleetion Qualifying Fees 601010 343800 Cemetery Lots �� LoUNiche�, Block %� , Unit � 001501 343805 Cemetery Fees �� }P Total Paid �y�T�L� Initial: White - Dept. of Origin • Ifellow - Finmce • Pink • Applicant �� i,y,��'�'� �. �� : HOMfE OF, PEUUN B1AND City of Sebastian Municipal Cemetery Purchase Receipt I I To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate regulations, residence of purchaser or person for whorn lot is intended for interment must be � /D Area Code & Phone�N'umber Residence Address of Intended Occupant if Other Than Purchaser Office Use Only Receipt is acknowledged in the sum of: Dollars ($/ o . od ) on this _�day of , 20�� for the purchase of the foliowing described Cernetery Lot( and/or Ni he(s). Unit �_, Block ��_., Lot(s) �'�- 8 Niche(s) for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. Addiiional Fees paid at time of purchase: Corner Markers (set of 4-$20) Opening & Closing �%Sa a �) O F� Circle One Vase and Ring for Niches (cost) Signature of Purchaser Interment Disinterment � �s" � d Service fees are to be paid at time of need only I:1W W-DATA\Ms-Cemetery�RECEIPT.doc Cl'l�` QF � �� ._� � � s�TT - �� .�, ,�-------� - 9i�.it�P�E �9F P��.i��i 8�€14h]C� January 15, 2004 Fortunato and Sandra Roma 433 Memorial Avenue Sebastian, Fl 32958 Dear Mrs. Roma: Enclosed is City of Sebastian Certificate Number 1938 for the purchase of Lots Number 7& 8, Block 16, 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. Sin�r,ely, _ f � � � ��7 � / �_. �, Sally A. Maio, CMC City Clerk SAM:ar enclosure