HomeMy WebLinkAbout4-15-17o,
Certificate # 1906
IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian,
it is hereby certified that:
Certificate of Interment Rights
Gregory John Shivers
(name)
(name)
rnr a
5~~~~~
M{K
HOME C+F PELICAN ISLAND
101 High Court, Sebastian, F1 32958
(address)
(address)
in and for consideration of the sum of $700.00 ,has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plot:
Unit 4 ,Block 15 ,Lot(s) 17
of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and regulations
prescribed therefore by the City of Sebastian.
CONVEYED THIS 11 thday of June
,..~.~..
City Manager
C OF SE STIAN, FLORIDA
~,°~
Terrence R. ore
~nn~
ATT T:
J
a y A. M 'o, CMC
City Clerk
~~ O.
Name
Unit ''t
..
Block `~
___
Lot '~
Date of Mark-out ~~ ~.. ~ ~ ~
Date of Burial ~ j ~' ~J
Name of Fune
Authorized by
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Name r~1 ~', 1.~~ ~`~ f ~/ f ' /~ ~ .~ f~ ~~ ~ {` _>d1~ % ~" lt,;~' 1}-t;iJ.1~ sf,:~ ~ ~' "?~~~r~':=7
Unit /
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Block / ~~ J
Lot ~ ~ ~' ~ ~ u.J ` 1 ~`!` Ul ~ l 0~ u ~ / ~~~ f? /~
Date of Mark-out
Date of Burial ! ~ ~ ,~~. Time /.~ . ~ ~' ~.:~ ~ '
Name of Funeral Home .'s~ !''K. ~~' ~-/ ~ '
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Authorized by f.~..f > .~'-~ I` ~ - ~ ~~
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S~BASTI~j W
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City of Sebastian Municipal Cemetery
Purchase Receipt
To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery
rate regulations, residence of purchaser or person for whom lot is intended for interment must be
provided at time of purchase
oh n ,~i~i ~~~.
Nam
Address ~
-~~~5~ ~~7~) 5si-ot~7~
Area Code & Phone Number
~E-'~cQ~t-i o-~
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Receipt is acknowledged in the sum of:
-,.
_._.;T~_'ti.
HOME OF PELiUN ISLAND
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Dollars ($~DD _ ~~ ° )
on this ~ ~ ~~' day of ~~ ~ e , 20 ~.~ for the purchase of the following
described Cemetery Lot(s) and/or Niche(s).
Unit ~ ,Block IJ` ,Lot(s) ~ 7 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 ~d~ ~O W O H
Cir One
Vase and Ring for Niches (cost) Interment
Disinterment
TOTAL $ C~oZ 5. ~v
Sign re Purchaser ' y of Sebastian
Service fees are to be paid at time of need only
I:\W W-DATA\Ms-Cemetery\RECEIPT.doc
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CITY OF SEBASTIAN
CITY CLERK'S OFFICE
RECEIPT
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AmourdPaid
001001 208001 Sales Tax
001501 322900 Garage Sales
001501 341920 CopiesBid Specs.
001501 341910 LDC/Code of Ordinances
001501 362100 Community Center Rent
001501 362100 Yacht Club Rent
001501 362150 Non Taxable Rent
001501 343800 Cemetery Lots
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601010 343800 Cemetery Lots `
LoUNiche ~~ ,Block f `~ ,Unit
001501 369400 Interment Fee
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001501 36940 ce
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680800 220681 Yacht Club Security Deposit
680800 220682 Community Center Security Deposit
680800 220683 Riverview Park Security Deposit
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White - Oept. of Origin • ~sllow -Finance • Pink • Applicant
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H~ ^ T ~ State of Florida, Department of Health, Vital Statistics
lyL APPLICATION FOR BURIAL -TRANSIT PERMIT
(TYPE)
~-~s~ ~~
Name of First Middle Last Date Month Day Year
Deceased of
Karen Kristine Shivers Death June 9 2003
Place of Death City, Town or Location
County
Brevard Micco Name of
Hosp. or
Inst. (If neither, give street address)
9880 Holl Street
Name of Medical Address Phone Number
Certifier S 'id S. Qaiser, M.D., M. 1750 Cedar Street
Medical Examiner Physician Rockledge, FL 321-633-1981
Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment 1623 N. Central Ave.
Strunk Funeral H me Sebastian, FL 1228 772-589-1000
Check a. U The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. ~ was contacted on
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that 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
of cjbus5~f death within 72 hours.
Funeral Director/ Si ture F.E. No./Reg. No. Date Signed
Di~s~B~spesar / 1862 6 / 11 / 03
BURIAL -TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228-03-0257
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.
Flegistrare+* / Date Date Certificate
Subregistrar Signature ~ `'~-~'~ir~..~ Issued: 6/9/03 Due: 6/14/03
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.
Method of Disposition:
BURIAL
CREMATION
Signature of Sexton
or Person-in-Charge
STORAGE
OTHER (Specify)
} o a.
CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemetery
Date of Disposition (~,/~y~
tis 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 county where disposition occurred.
Distribution: While: Cemetery or Crematory
326, 6/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
ock Number 5740-000-0326-2) Pink: Local Registrar
AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA