HomeMy WebLinkAbout4-15-35~.
f~YflF
+~~,~l~-S7C1[,
HOME OF F'EUGN IStJ4ND
Certificate # 1936
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Carmen Wilson
(name)
114 LaPlaya Lane, Sebastian, Fl 32958
(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)_35_
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 9`h day of January, 2004.
' Y OF SEB STIAN, FLORIDA
erre .Moore
City Manager
ATTEST:
,.
_..~,. ~;a~~
Sal A. Maio, CMC
City Clerk
~ . ~ ~ ,, .,~/ ~ J ~ ~ ~
Name
Unit
Block ' j`,,,
Lot y'~ ~'
Date of Mark-out
Date of Burial /~~! %',.~~ ~~ ~ Time I ~ ' %''~ ~'~ "
r~ /~
Name of Funeral Home
~`
Authorized by ' '~ ~~~ '` `~
f ----~~,-r--~
QIY OF
S~B~T~N
_~.
J
HOME OF PELICAN ISLAND
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
provid/e~d at time of purchase 1
( ~,I .r rn~ ~ ~~lJ ~ I SoN
Name(s)
l-0. ~~ ava ~.n-
a
3Z4S't~
Address
~ -~na- ~~-~g 33
Area Code & Phone Number
2v Nev;ll-e ; I ao~
Residenc Address of Intended Occupant if Other Than Purchaser
O>rfice Use Only
acknow~edged in the sum o
%~
T
on this day of
describ d Cemetery Lots /or Ni e(s).
Dollars ($ d . ~ )
20~ for the purchase of the following
Unit ,Block +~, Lot(s) ~vr- 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 y/ ~ d~ O H
Circle One
Vase an~.Ri~g for Niches (cost) Interment _~~ D
re ~Sf Purchaser ~ty of Sebastian Gj `
Service fees are to be paid at time of need only
I:1W W-DATA1Ms-Cemetery\RECEI PT.doc
January 12, 2004
Mrs. Carmen Wilson
114 LaPlaya Lane
Sebastian, Fl 32958
Dear Mrs. Wilson:
Enclosed is City of Sebastian Certificate Number 1936 for the purchase of Lot Number 35,
Block 15, Unit 4. Also enclosed is a copy of your receipt and the Rules and Regulations
governing the Sebastian Municipal Cemetery.
If you have any questions, please contact our office.
Sincerely,
~~, ,, ~ ,,
Sall A. ~aio CMC
Y ,
City Clerk
SAM:ar
enclosure
N o ~,
Cep ~ ~ ~ca~
M ~g
~m
~
~ ~
o
~ /
w `'~
o r
r e
~~ r
--~~
n .~
~;
w ~--~
~ ~~
J~~
~wrn
¢m
W
~
~.
`
J 'J
v
iLL
Z ~
ZZ
~gF zm
~e°
0
~
~~m
Zn~ ~
~ m
x ~~
~L~
_
~~ mV
~ a
a
VV
V//
w ~ ,~
a.~c~
~X ~,.~
ti
S
l
0'
O
O
O
O
O
ru
S
~.D
D
O
D
..
v
Y1
0
LL
sa
C~ oOG°p17
CITY OF SEBASTIAN
CITY CLERK'S OFFICE 2 4 3 8
RECEIPT -
N e ~ / ^ Cash
Date eck ~~
No• Amount Paid
001001208001 Sales Tax
001501322900 Garage Sales
001501 341920 CopieslBid Specs.
001501341910 LDC/Code of Ordinances
001501341930 ' Election Qualifying Fees
601010 343800 s
Cemetery Lot~
/~ /
~
,~.
/Ni
L
2' ~~
~
ot
che~
s.~, Block Unit
001501343805
Cemetery.Fees s-'
~ ` dG
T I Paid~`~~ ~6
ite -Dept. of Origin • Yellow -Finance • Pink • Applicant
yo~~
HEALTH State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL -TRANSIT PERMIT
a.
1. Name of First Middle Last Date Month Day Year
Deceased of
ROY TJ.F WILSON ~ Death JAN. 7, 2004
?. Place of Death Ciry, Town or Location
County
INDIAN RIVER VEOR BEACH Name of
Hosp. or
Inst. (If neither, give street address)
TANDEM HEALTH CARE
3. Name of Medical Address Phone Number
Certifier GARY R. SILVIIiMAN, • MD 777 37TH ST
Medical Examiner Physician VERO BEACH, ~ 32960 772-770-0500
t. Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment 735 FLEMTNG STREET
SEAWIIIDS F[TE[IltAL HOME SEBASTIAN, FL 32958 2617 772-589-1933
>. c:necK a. bl~ I ne medical certttication nas 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
medical certification of cause of death within 72 hours.
S. Funeral Director/ S~ ature F.E. No./Reg. No. Date Signed
Direct Disposer 2294 1/9/04
;. BURIAL -TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 04-2617-008
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.
Registrar or Date Date Certificate
Subregistrar Signature Issued: 1/9/04 Due: 1/14/04
,. 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 ~,~,~% i ~ ~ ~~°~~ ~~'~ .
BURIAL STORAGE Date of Disposition ~~ 3 ~d 'y.
~~ s
CREMATION
Signature of Sexton
or Person-in-Charge
OTHER (Specify)
"his 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
iithin 10 days to the local County Health Department in the county where disposition occurred.
Distribution: White: Cemetery or Crematory
H 326, 8/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
hock Number: 5740-000-0326-2) Pink: Local Registrar