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Home My WebLink About4-15-28Name Ce F 'A— 11-2 Unit �+ Block J Lot Date of Mark -out l Date of Burial % 1 I Time.2 eop Name of Funeral Home -5/ Authorized by CITY OF SEBASTIAN 10407 ADMINISTRATIVE SERVICES RECEIPT Name % U 2� U Cash Date l �a. aat �l e(Check #75 ❑ Credit Amount Paid 001001 208001 Sales Tax 001001 220000 Security Deposit 001501 362100 Taxable Rent 001501 362150 Non -Taxable Rent 450010 369900 Airport Badge 001001218010 CobraServe 001501 354100 Code Enforcement Fines 001501 347557 Community Center Revenue 001501341920 Copies 001501 351140 Parking Citation 001501 342100 Police Security Services 001501 329200 Site Plan Review 001501 329300 Subdivision/Plat Review 001501 329100 Zoning Fees Qouuoi 34-32o5 01c, 14 -k -0--w OwL4 61�1�, s 1joT Total 'dl6 I Is Security Dep Held - Amount $ Check N White - Dept. of Origin • Yellow - Admin. Svcs. • Pink - Applicant FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY For information contact: Kip Kelso, Cemetery Sexton j� Sebastian Municipal Cemetery Phone: (772) 589-2545 Fax: (772) 228-9927 n �kJ City Clerk's Office - Cathy Testa 1J �\ City Hall, 1225 Main Street Sebastian, FL 32958 Office (772) 388-8215 or 388-8214 ctesta cDcitvofsebastian.org FUNERAL HOME: Strunk Funeral Home and Crematory ADDRESS: 1623 North Central Avenue, Sebastian, Florida, 32958 PHONE#: _772-589-1000 (Check One) XXXX OPEN BURIAL LOT OPEN CREMAINS LOT OPEN COLUMBARIUM NICHE Lot-28—Block 15Unit 4 Lot—Block—Unit Niche Block Unit N S E W BURIAL DATE AND SERVICE TIME: 1/19/2017, THURSDAY -GRAVESIDE SERVICE 2:00 PM FOR DECEASED: Evelyn Elizabeth Nash Royer Name NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership) David L. Royer AAV%d L. 1zDuer 1/11/2017 Name Signature Date I certify that I have determined the ownership of the above described site that all site fees and administrative fees have been paid and authorize opening of same. NAME AND SIGNATURE OF LICENSED FUNERAL DIRECTOR: William B. Whittaker, Jr. CkAHiaWtB CAittap2ll., A 1/11/2017 Name Signature Date Cemetery Sexton Certification: I certify that I have checked the ownership information by viewing the owner's deed and confirming with Clerk's office and that allfe s ha i been paid: �7, Cemet ry S XtO6 Date This form to be provided to CI rk's Office by Sexton for permanent record upon completion. State of Florida, Department of Health, Bureau of Vital Statistics — --- BURIAL TRANSIT PERMIT HEALTH DATE PRINTED: January 10, 2017 TRACKING NUMBER: 2017004985 1. DECEDENT INFORMATION Name of Deceased Date of Death EVELYN ELIZABETH NASH ROYER January 9, 2017 Place of Death - County City, Town or Location Name of facility, or street address if not a facility INDIAN RIVER VERO BEACH INDIAN RIVER MEDICAL CENTER Name and Address of Funeral Home/Direct Disposal Establishment Fla. Lic. No./Reg. No. Phone Number STRUNK FUNERAL HOME- SEBASTIAN F041870 F041870 (772) 589-1000 1623 N CENTRAL AVE SEBASTIAN, FLORIDA, 32958 Funeral DirectorlDirect Disposer Fla. Lic. No.IReg. No. WILLIAM B. WHITTAKER F026900 2. BURIAL - TRANSIT PERMIT The Florida Department of Health, Bureau of Vital Statistics hereby grants permission to dispose of this body in accordance with Chapter 382, Florida Statutes. Permit Number: 2017-FO41870-5005 �'=-- Date Issued: January10, 201717 State Registrar 3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL-AT-SEA, or HOSPITAL DISPOSITION Authorization given by Medical Examiner District Approval Number: 4. CEMETERY OR CREMATORY J Place of Disposition: SEBASTIAN CEMETERY 1 hWi / I %i j Method of Disposition: BURIAL Date of Disposition: I I Ov r l EDRS maintains all statutorily required information regarding the death record and related burial transit permit, therefore, returning the permit to the county health department is no longer required. If the Place of Final Disposition wishes to retain the copy of the permit for their file they may do so. DH 326E, 10/12 64V-1.011, Florida Administrative Code --J.. ~„ ~~ 5~~~~'~' HOME OF PEUUN ISU~ND Certificate No. 2027 Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Charles H. and Evelyn Royer 1570 Bevan Drive, Sebastian, Fl 32958 (name) (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 15 Lots 27 & 28 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 5th day of July, 2005. CITY F S B STIAN, FLORIDA ATTEST: . (~~-~~~ Gr-c J~pu+y C ~ fy Clerk A Minner ~ Sally A. Maio, MMC City Manager City Clerk