HomeMy WebLinkAbout4-18-24CITY OF
~~~~~~1~~~~~~
HOME OF PELICAN ISLAND
Certificate No. 2198
C~~~ ~~~ ~~~.~~~~~
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Keith &/or Kathleen King 220 Nesbitt Street NE, Palm Bay, FL 32907
(name) (address)
In and for consideration of the sum of $4,000.00 is entitled to full interment
rights in the Sebastian Municipal Cemetery for the following lots:
Unit 4, Block 18, Lots 24 & 25
of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and
regulations prescribed therefore by the City of Sebastian.
CONVEYED THIS 14t" day of November, 2008.
SEBASTIAN, FLORIDA
AI Minner
City Manager
ATTF~T:
.~f , 7 ~~_~~,__,
~~ ,
Sally .Maio, MMC
ity Clerk
Name
.r f
Unit
Block ~f~~
Lot ~ ~~
,i?.
f
Date of Burial ,~~_~~/~ ~ ~ f~ ~ Time ,~ ~ .,.;r._ ~ i (: ~~F ~t .~ '`
f°
...-~..
--' ~ r1
Name of Funeral Home ~' ~-- ~ ` '~ ~ ~~"'~~ "'" ~ '" ~1
/f ,
Authorized by ' l -~~ ~ }'`1 ~ f ~-~ i ~ ~ ` ( ~ 1
P
f
d ~j
S N f
m
I
o
v
~
~.
~
.
0
n
_'
E
r'
m
v
e
~
a
9 ~
°~
{
Y ~
~
d
`.
~
^
V
p
O
~ O
O S O O O
O O
O =
C
S O
0 (r
0 Gr
0 C7i
0 CJt
0 O
0
(J
W
O
(T W
OD
O ((
.,~~
A
(O
O ((
~~
A
tD
O ((
,,~~
Js
c0
O N
O OOD
~
m I o C7 m r C~ G7 fn
~ ~ n v° m w
~~
~ ~ a° ~ ~
~ ~
Q ~~
3r LA
~_
d d
m 3
rm
~A~~. A
v
~~
O ~
c I~
c_ ~ ^
n ~
N ~
~ S
a
a
0
C4
Q a -Q
i "~
~~
mm0
mom
~HW
'i0y
T ~
T S
m=
N
~,
fI11' of
_, ~
~t~
~-~- ~
HCfME ®F PELICAN fSLAtd€?
City of Sebastian Municipal Cemetery Purchase Receipt
To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate
regulations, proof of City residency of purchaser or person for whom lot is intended for interment must
be provided at time of purchase.
Name(s) ~ ~ N es ~ ~ ~`~~- S-~ ~"~- ~~' ~ ~J f~ ~ ~~ L~c~ y ;cL :3 Z~r ~~ .7
Address '
Area Code & Phone Number
Name & Residence Address of Intended Occupant if Other Than Purchaser
OFFICE USE ONLY
Receipt is acknowledged in the sum of:
~"L.A/1...~~"1.(,QL~~ .GU~~I ~(5-0 ~~------~ Dollars ($ dQU~ t~~
on this- ~3~ ti day of /v~' V ~ to ~ ~' , 20 (~ ~ for the purchase of the following described
Cemetery Lot(s) and/or Niche(s).
Unit ~, Block ~ 4 ,Lot(s) ~~ '~ ~J 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
Vase and Ring for Niches (cost)
Interment
Temporary Marker Preparation & Installation
S' nature of rchase
/W O H
Circle One
Disinterment
TOTAL $~~ ~~~~~~i
~~~ ~~~~~
' y of Sebastian
The following documents were provided as Proof of
Residency:
1:1!1lM!-DATA\Ms-Cemetery\RECEIPT.doc
and
CITY OF SEBASTIAN
CITY CLERK'S OFFICE
RECEIPT /'
4 Z O S
fK%
n
Name ~ 0 Cash
Date ~ ~"~ ~J + y6 ,Check#~
No. Amount Paid
001001 208001 Sales Tax
001501 322900 Garage Sales
001501 341920 CopiP,slBid Specs.
001501 341910 LDC/Code of Ordinances
001501341930 Election (]ualifying Fees
i
c. ~
Q~
601010 343800 Cemetery Lots ;
UNi
h
~ Bl
k ~ ~
L U
it
o
c
e
oc ,
n
001501 343805 Cemetery Fees
/ w~7~ Total Paid ~ ~~~
Initials
White -Dept. of Origin • Yellow -Finance • Pink -Applicant
FLORIDA DEPARTMENT OF
HEALT
A. (TYPE)
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL -TRANSIT PERMIT
1. Name of First Middle Last Date Month Day Year
Deceased of
Keith Kin Death December 3 2008
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Brevard Palm Ba Inst. William Childs Hos ice House
3. Name of Medical Address Phone Number
Certifier John K. Campbell MD 7125 Murrell Road
Medical Examiner x Physician Vi era FL 32940 (321) 242-8790
4. Name of Funeral Home/Direct Disposal Address Fla. Lic_ No./Reg. No. Phone No. (Area Code)
Estabfisnment- 15465 1001 Soutfi Hickory Stree~i, -
South Brevard Funeral Home Melbourne FL 32901 F041850 (321) 724-2222
5. Check a. ~ The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b' ® H1L~a1Cp was contacted on IZ~IZSf2130~
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that .lnhn K _ (:am~nhel l MIl will complete and sign the medical
certification of cause of death within 72 hours.
c.
was contacted on
Helshe verified that
Medical Examiner, will complete and sign the
medical certification of cause of death within 72 hours.
6. Funeral Director! / Signature F.E.'No/.;/Reg. No. Date Signed
Direct Disposer _ / ~`^t/~~`J ~ ~'7~~'1-~--~- Fn `~ G~"~ ~~ 1 9 ~n~ ~nf2
B. BURIAL -TRANSIT PERMIT
- - Permission is hereby granted to dispose otthis body. _ _ _ _ _ _ _ _ _ _- - _ ___ Permit No. __ r 01$50=355-~
X~ 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 wii! 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.
Registrar or '( "' Date Date Certificate
Subregistrar Signature issued: , o inc ino Dye: ~ o ~~ ~ ~~~
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. Awaiting period of 48 hours after death is
required for all cremations.
D. CEMETERY OR CREMATORY
Methoaf of Disposition: Place of Disposition $pha cti an Ci tv ('amatarv
BURIALSTORAGE Date of Disposition ~~ %~~
CREMATION OTHER (Specify)
Signature of Sexton
or Person-in-Charge
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, 8/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number: 5740-000-0326-2) Pink: Local Registrar ~ `~ >~