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Certificate # 1903
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HOME OF PEUUN ISUND
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian,
it is hereby certified that:
Glen Rohm 1614 Coral Reef Street, Sebastian, F1 32958
(name) (address)
(name) (address)
in and for consideration of the sum of $ 7 00 . o o ,has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plot:
Unit 4 ,Block 15 ,Lot(s) 9
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 29th day of May 2003 .
CITY OF SEBASTIAN, FLORIDA AT ST:
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Terrence R. ggre a y A. 'o, CMC
City Manager City Cler
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Unit 7
BI`ock ~-_- _ ._
Lot 7
Date of Mark-out %~! ~ ~~' ! ~`
Date of Burial ~ / ! / o ~ Time_
Name of Funeral Home ~- /~ w ~%`h ~ •
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Authorized by ~---- }~~ f
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HOME Of PELICANISLAND
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
G L E,~ ~l'a
Name(s) ~ _
Address
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Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Receipt ' acknowledged in the sum of:
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Dollars ($ ~~D- ~~ )
on this ~ ,~ day of , 20 ~ for the purchase of the following
described Cemetery Lot(s) and/o fiche(s).
Unit ~, 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 - o d
Vase and Ring for Niches (cost)
Signature of Purchaser
Service fees are to be paid at time of need only
W O H
Circle One
I:\W W-DATA\Ms-Cemetery\RECEIPT.doc
Interment Disinterment
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.:~• ~ '• TENNESSEE DEPARTMENT OF HEALTH
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;;'~•~ ;~, . PERMIT FOR FINAL DISPOSITION OF HUMAN REMAINS
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ame o unera erec/~to`r or erson ctmg as uc ame o tte ing ystc~an
ess o uner erector or erson ctmg as uc
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I hereby apply for a permit for the final disposition of the remains of the above named decedent. I agree to
abide by all laws and rules of the Tennessee Department of Health and all other laws pertaining to the
preparation, .container, transportation, burial and/or cremation of same. The type permit needed is checked
Application below. If I have not been able to submit a properly completed certificate of death for this person at the
for Permit time of this application, I agree to file within three days the required record with the local registrar in the
county where the death occ d.
Signature Address
TYPE OF PERMIT REQUESTED (Check all that are applicable.)
O B real O Cremation O Disinterment
Transit O Scientific Use O Reinterment
l Name and ~ e~ss of Cemetery where Remain ~ to be ~rred r / ~~~'~ y~/ J
Buria
Name and Address of Crematory where Remains are to be Cremated
Cremation
From To
Transit ~., ~~ ~ ~~
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Removed From ame and Address of Cemetery)
Disinterment
Place of Reinterment (Name and Address of Cemetery)
Reinterment
Name and Address of Facility Receiving Remains
Scientific Use
I consent to the issuance of the Permit for Final Disposition.
Physician or Medical
Examiner Signature of Attending Physician or Medical Examiner* Address
*Authorization of the Medical Examiner is required for a cremation permit.
This permit for the final disposition of the remains of the above named is granted for the purpose(s) checked above.
Permit of
Local Registrar
Signature of Local Registrar Address
I certify that the disposition of the remains of the above named was made in accordance with this permit on
at
Certification of Date Place
Person in Charge Signature
of Disposition
Address
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PH-1687 (Rev. 8/97 ~~,,~~'~--~~ % J~~~~a~ ~~~- ~" ~ G_~ ~~,,~' RDA 1468