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Certificate # 1924
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian,
it is hereby certified that:
Patricia Leisch
(name)
(name)
1573 Damask Lane, Sebastian, FL 32958
(address)
(address)
in and for consideration of the sum of $700.00 ,has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plot:
Unit 4 ,Block 15 ,Lot(s) 33
of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and regulations
prescribed therefore by the City of Sebastian.
CONVEYED THIS 10th day of November , 2003
CITY OF SEBASTIAN, FLORIDA ATT/'E~ST~:
_L---~
~°
errence R. oore Sally A. M ' , CMC
City Manager City Clerk
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Name --- A ~ ` ,rte/ i f ~...'}~' r; elf ~-~- ~~
Unit
Block _L.
Lot ~ J
Date of Mark-out
Date of Burial °'~ / ~~' ~ ~ ~~ ~ Time f / ~' ~~
t
Name of Fune
Authorized by
QIY Oi
S~~-s~u~N ~~z
HOME OF PEUUN ISIAND
City of Sebastian Municipal Cemetery
Purchase Receipt
To enable the City of Sebastian to determine the convect rate, and in accordance with cemetery
rate regulations, residence of purchaser or person for whom lot is intended for interment must be
provided at time of purchase
PPrrRi ~; q Liriscl~
Name(s)
15`i 3 ~'Da ~~ s k L~-~-~ s~ ~ A s-n'A ~ , 4G ( 3 2 9 S 8
Address
7~2 - S'8~ - 87h ~
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Receipt is acknowledged in the sum of:
~~ ~.,,,,~J a.~Q ~..~t ~~---"' Dollars ($ 700. ~o 0
on this 4 day of Nod , 20 03 for the purchase of the following
described Cemetery Lot(s) and/or Niche(s).
Unit ~ ,Block ~ 5 ,Lot(s) 3~ 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
Signature Purchaser
Service
of Sebastian
AL,~ 77~ a 13
to be paid at time of need only
~ S. 00
W O H
Circle One
Disinterment
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November 13, 2003
Patricia Leisch
1573 Damask Lane
Sebastian, Fl 32958
Dear Ms. Leisch:
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Enclosed is City of Sebastian Certificate Number 1924 for the purchase of Cemetery Lot 33,
Block 15, Unit 4. Also enclosed is a copy of the Rules and Regulations governing the Sebastian
Municipal Cemetery.
If you have any questions, please contact our office.
Sin y,
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- Sally A. aio, CMC
City Clerk
SAM:ar
enclosure
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CITY OF SEBASTIAN
CITY CLERK'S OFFICE
RECEIPT ,.
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~ [ [
Name t. ~ ,Y
ash
r
Date l ~
Check #_'~~_
No. Amount Paid
001001208001 Sales Tax
001501322900 .Garage Sales
001501341920 Copies/Bid Specs.
001501341910 LDC/Code of Ordinances
001501341930 Election Qualifying Fees
601010 343800 Cemetery Lots
lotMich~,_y,~, gl~ -,~ Unft
001501343805 Cemetery Fees
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Total Patd ~ ~~ ~
itials
White -Dept. of Origin • Yellow -Finance • Pink • Applicant
r-
FLORIDA DEPARTMENT OF
HEALT~
A.
y~sj33
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
JACK C. GODDARD Death NOV. 2, 2003
?. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
INDIAN RIVER ROSE'LAlID Inst. SEBASTIAN RIVER MEDICAL CENTERS
3. Name of Medical Address Phone Number
Certifier ZiOHAMMAD IDREES, MD 7762 BAY ST
SEBASTIAN, FL 32958 772-589-0069
Medical Examiner Physician
t. Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment 735 FI.ElIING ST
SEAWINDS F[JNERAL HOME SEBASTIAN, FL 32958 2617 772-589-1933
i. Check a. ® The medical certification has been completed and signed. A completed certirficate 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
medical certification of cause of death within 72 hours.
Funeral Director/ Sig ature~' F.E. No./Reg. No. Date Signed
Direct Disposer ~' 2294 11/3/03
BURIAL -TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 03-2617-137
~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 ce ica a has been requested.
Registrar or Date Date Cert'rficate
Subregistrar Signature Issued: 11/3/03 Due: 11/7/03
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.
CEMETERY OR CREMATORY ~ `
Method of Disposition: Place of Disposition = ~,¢ /r
'BURIAL ~ STORAGE Date of Disposition ! / / ~' ~ /~>
-T ~
CREMATION ~ OTHER (Specify)
Signature of Sexton 1
or Person-in-Charge JT -
pis permit must be endorsed by the Sexton orperson-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.
DisMbution: Whhe: Cemetery or Crematory
326, 8/97 (Obsoletes all previous edAions) Yellow: Funeral Director or Direct Disposer
Eck Number. 5740-000-0328-2) Pink: Local Registrar