HomeMy WebLinkAbout1-29-03CRY OF
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HOME OF PELICAN ISLAND '
Certificate No. 1988
T 0 ; $ ST'tA.!`_
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Daniel Lee & Rebecca Yates 12760 Roseland Road, Sebastian, Fl 32958
(name) (address)
in and for consideration of the sum of $700.00 has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plot:
Unit_ 1_ Block _29_ Lot _3_
of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and regulations
prescribed therefore by the City of Sebastian.
CONVEYED THIS 21th day of September, 2004.
City Manager
ATTE
San.yA.Maio, CMC
City Clerk
Name __3-�/
/ Unn____�_
Block
Lot
Date of Mark-out VAO
Time o�oorovnai
Name o, Funeral Home
Authorized by
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SEBASTKN
HOME OF PELICAN ISLAND
City of Sebastian Municipal Cemetery
Purchase Receipt
To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery
rate regulations, residence of purchaser or person for whom lot is intended for interment must be
provided at time of purchase
Name(s) v`
Id, 1 a te 4 a,, �-_- "y .zw
Address
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Recei t is acknowledged in the sum of:
Dollars ($ 4D "�, d )
on this day of , 20_!e for the purchase of the following
described Cemetery Lot(s) a d /or Niche(s).
Unit /_, Block rte(/ , 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 C'O 0 H
Circle One
Vase and Ring for Niches (cost) Interment Disinterment
Signature of Purchaser
ity of Sebastia
TAL $
Service fees are to be paid at time of need only
1: \W W- DATA \Ms - Cemetery\RECE I PT.doc
SIEBASTIAN
HOME OF PELICAN ISLAND
1225 Main Street, Sebastian, Fl 32958
Telephone (772) 589 -5330 — Fax (772) 589 -5570
September 21, 2004
Mr. & Mrs. Daniel Lee Yates
12760 Roseland Road
Sebastian, Fl 32958
Dear Mr. & Mrs. Yates:
00 p�
Enclosed is City of Sebastian Certificate 1988 for the purchase of Cemetery Lot 3, Block 29,
Unit 1. 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 ely,
Sall A. 2aio,CMC
Y
City Clerk
SAM:ar
enclosure
Total Paid zz, eo
Initials
- White - Dept. of Origin • Yellow - Finance a Pink • Applicant
CITY OF SEBASTIAN
CITY CLERK'S OFFICE
RECEIPT
3112
Nam e_�s
iv
0 Cash
Date
C'
heck 1.;'s% d
No.
Amount Paid
001001 208001
Sales Tax
001501322900
Garage Sales
001501341920
Copies/Bid Specs.
001501341910
LDC /Code of Ordinances
001501341930
Election Qualifying Fees
7d
601010 343800
Cemetery Lots
I.. f.?
Lot/Niche U Block,,;,% Unit
001501343805
Cemetery Fees
S ee
Total Paid zz, eo
Initials
- White - Dept. of Origin • Yellow - Finance a Pink • Applicant
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FLORIDA DEPARTMENT OF State Health, Statistics !' l
fi� � APPLICATION FOR BURIAL TRANSIT PERMIT
A. (TYPE)
1. Name of First Middle Last Date Month Day Year
Deceased of
Shirley Leona LaRosa Death Sept. 14 2004
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Brevard Melbourne Inst. Wuesthoff Health System
3. Name of Medical Address Phone Number
Certifier Mi rMedical el Lorente, M D. 250 N. Wickham Road
Examiner Physician Melbourne, FL 32935 321- 752 -1200
4. Name of Funeral Home /6iF�o l Address Fla. Lic. No. /Reg. No. Phone No. (Area Code)
Establishment 1623 N. Central Ave.
Strunk Funeral Home Sebastian FIL 7228 772- 589 -1000
5. Check
Appropriate
Box
a
ff
The medical certification has been completed and signed. A completed certificate of death accompanies this
application.
b. r Stephanie was contacted on 9/15/04
He /she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. Lorentes 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
medical c rtificati ause of death within 72 hours.
6. Funeral Director/ ign re F.E. No. /Reg. No. Date Signed
9/15/04
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No.1228 -04 -0357
E] 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.
I40g+strnte+, Date Date Certificate
Subregistrar Signature Issued: 9/15/04 Due: 9/20/04
C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA
I
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:
iBu RIAL
CREMATION
Signature of Sexton
or Person -in- Charge
STORAGE
OTHER (Specify)
.[
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/ 1 % Ls -
CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemetery
Date of Disposition �X� Z) Z
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