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Home My WebLink About4-14-20i aIr or SERAST_" NOME OF PEUGIN ISLAND Certificate # 1880 C�Op� Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Maria M. Rios 2096 Paradise Court, NE, Palm Bay, FL 32905 (name) (address) (name) (name) (address) (address) in and for consideration of the sum of $1,125.00 , has purchased and is entitled to full interment rights in the Sebastian Municipal Cemetery for the following plot: Unit 4 , Block 14 , Lot(s) 20 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 17th day of March CITY OF SEB STIAN, RID A Terrence R. M016re City Manager 2003 ATTEST: Sally A. W10, CMC City Clerk Name Unit Block Lot ti A Date of Mark-out Date of Burial Time Name of Funeral Home Authorized by---- .0 LU LL CO) CO w ru LL. LU LU CO -6 CO x M 1 10 M (0 U) f'- .9 ( �I Q) (n C) Q) LL CO 79 • E .2 2 = C '0 -M 0 Z3 a) (D S2 CZ C? E E a) .2 :E E ro a) 0 E j C) 0 0 Cn CY) 41 9 § le CI) 5 L g § co te 8 C) CO Cn Seawinds Date 4 -2 -03 001501 369400 001501 369400 680800 220681 680800 220682 680800 220683 CITY OF SEBASTIAN CITY CLERK'S OFFICE 1643 RECEIPT 0 Cash 11 Check It 2231 AmountPald Sales Tax Garage Sales Copies/Bid Specs. LDCICode of Ordinances Community Center Rent Yacht Club Rent Non Taxable Rent Cemetery Lots Cemetery Lots Lot/Niche , Block Unit _ U4 B14 L20 Fernandez Interment Fee U1 B28 L12 Dellerman Weekend Service Yacht Club Security Deposit Community Center Security Deposit Riverview Park Security Deposit 75.00 125.00 i f i, i R DEPARTMENT OF ALT A. (TYPE) 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 was contacted on DOMINGA ORTIZ— FERNANDEZ Death MARCH 11 2003 2. Place of Death City, Town or Location Name of (If neither, give street address) was contacted on He /she verified that County Medical Examiner, will complete and sign the Hosp. or medical certification cause o death within 72 hours. BREVARD PALM BAY Inst. 2096 PARADISE COURT NE 3. Name of Medical zi Address AL - TRANSIT PERMIT Phone Number Certifier SANGITA SAHAY, M.D. 1081 PORT MALABAR BLVD 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. Medical Examiner 1=2 jPhysician PALM BAY, FLORIDA 32905 Registrar or 321 - 729 -9306 4. Name of Funeral Home /Direct Disposal Issued: 3/11/03 Due: 3/14/03 Address Fla. Lic. No. /Reg. No. Phone No. (Area Code) Establishment Approval Number: 735 FLENIING STREET SEAWINDS FUNERAL HOME SEBASTIAN, FLORIDA 32958 2617 772/589 -1933 5. Check a. 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 medical certification cause o death within 72 hours. 6. Funeral Dir or/ signature F.E. No. /Reg. No. Date Signed Direct Disp (� 3114 3/11/03 zi B. AL - TRANSIT PERMIT Permission is hereby g 6ante/to di spose of this body. Permit No. 03- 2617 -30 79' A five (5) day extensi 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 eath certificate has been requested. Registrar or Date Date Certificate Subregistrar Signature Issued: 3/11/03 Due: 3/14/03 C. 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. A waiting period of 48 hours after death is required for all cremations. D. CEMETERY OR CREMATORY _ Method of Disposition: Place of Disposition �� 5 �/ ,�" „Lh r' % ffe i/ OKURIAL STORAGE Date of Disposition TS/ /e, CREMATION Signature of Sexton or Person -in- Charge OTHER (Specify) This 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 within 10 days to the local County Health Department in the county where disposition occurred. Distribution: White: Cemetery or Crematory DH 326, 8197 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer (Stock Number 5740 -000- 0326 -2) Pink: Local Registrar The Sebastian Cemetery City ®f Sebastian, Florida Receipt is acknowledged in the sum of. no /100 One Thousand, One hundred, twenty -five and Dollars ($1,125.00 ) From: M0, 10, a M.'R .10 S �l I) 9q,4 _ ('-17c-, on this 13 day of 20 for the purchase of the following described Cemetery Lot(s)/Niche(s) upon the terms and conditions as stated herein: Description of Property: Cemetery Lot(s)/Niche(s) 20 Block 14 Unit 4 Purchase Price: One Thousand, One Hundred, Twenty- fiveayjos 1,125.00 ) Terms and Condition of Sale: This contract shall be binding upon both parties, the seller and the purchaser, when approved by the owner of the property above described. I, or we, agree to purchase the above described property on the terms and conditions stated in the foregoing instrument: xg�- �ic2 Purchaser signature Purchaser signature The City of Sebastian agrees to sell the above mentioned property to the above named purchaser(s) on the terms and conditions stated in the above instrument. 64ty of Sebastian 5vitness