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Home My WebLink About4-14-27�(1 X11 SEBASTIAN M� HOME OF PELICAN ISLAND Certificate # 1921 CIT Y Of SERA TI I NI Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Seawinds Funeral Home for Armando Roman Fellsmere, F1 (name) (name) (address) (address) in and for consideration of the sum of $950.00 , has purchased and is entitled to full interment rights in the Sebastian Municipal Cemetery for the following plot: Unit 4 , Block 14 'Lot(S) 2 7 of the Sebastian Municipal Cemetery, as maintained on file in the records of the City Clerk for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. CONVEYED THIS 27 th day of October , 2003 CI OF SEB TIAN FLORIDA ATTEST: 0 1� ac t/ Terrence R e �Vr Sally A. Maio, CMC City Manager City Clerk O O Name t t �1 ►7 f %� iW�-t Unit Lot 12 7 Date of Mark -out Date of Burial 3 Time / �" 40 /gym Name of Funeral H9.4e � WrnA s t Authorized by - --"' r SEBASTEa HOME OF PELICAN ISLAND City of Sebastian Municipal Cemetery Purchase Receipt To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate regulations, residence of purchaser or person for whom lot is intended for interment must be provided at times purchase (s) O-ir7.: Address ' 'Area Code & Phone Number Residence Address of Intended Occupant if Other Than Purchaser Office Use Only Receipt is acknowledged in the sum of: described Cemetery Lot(s) and /or Niche(s). Unit , Block Lot(s) Niche(s) lars ($ .Irchase of the following 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 W O H Circle One Vase and Ring for Niches (cost) Interme Disinterment OTAL $ sig6a re of Purchaser City of Sebastian are to be paid at time of need only I: \W W- DATA \Ms - Cemetery\REC EIPT.doc FLORIDA DEPARTMENT OF HEALT 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 ARMANDO ROMAN of OCT. 25, 2003 Death 2. Place of Death City, Town or Location Name of (If neither, give street address) County Hosp. or INDIAN RIVER VERO BEACH Inst. INDIAN RIVER MEMORIAL HOSPITAL 3. Name of Medical Address Phone Number Certifier MOOR M. MERCHANT, MD 13060 US 1 Medical Examiner % Physician SEBASTIAN, FL 32958 772 - 589 -0879 4. Name of Funeral Home /Direct Disposal Address Fla. Lic. NoJReg. No. Phone No. (Area Code) Establishment 735 FLEMING ST SEAWINDS FUNERAL HOME SEBASTIAN, FL 32958 2076 772 -589 -1933 5. 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 medical certification of cause of death within 72 hours. 6. Funeral Director/ Sig re F.E. No. /Reg. No. Date Signed Direct Disposer L , - 2294 10/26/03 B. BURIAL - TRANSIT PERMIT :)o. Permission is hereby granted to dispose of this body. . Permit No. 03 —RM -133 F�A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been reguested 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 / bate Date Certificate Subregistrar Signature / Issued: 10/26/03 Due: 10/30/03 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 Dispositions / l h/ RBLIRIAL ❑ STORAGE Date of Disposition / ?�/2.�? A> 3 CREMATION OTHER (Specify) Signature of Sexton or Person -in- Charge_ 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) Yp Ilow: Funeral Director or Direct Dispo er (Stock Number: 5740 -000 0326 -2) �i7 %� T nk: L I Registrar CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT 2274 �- Name ash Date lo heck # q— No. Amount Paid 001001 208001 Sales Tax 001501322900 Garage Sales 001501341920 Copies/Bid Specs. 001501341910 LDC /Code of Ordinances 001501341930 Election Qualifying Fees 601010 343800 Cemetery Lots Lot1Nichk-Z,,..5_ Block —� Unit 001501343805 Cemetery Fees adm-t �1-1- �--- �;77' �e Total Paid�J itials White - Dept. of Origin a Yellow - Finance • Pink - Applicant D No. ' 001001208001 001501322900 001501341920 001501 341910 001501341930 601010 343800 001501343805 CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT 2213 sh 0 Check# Amount Paid Sales Tax Garage Sales Copies/Bid Specs. LDC /Code of Ordinances Election Qualifying Fees Cemetery Lots LoUNlchX4 — Block Unit �"-- Cemetery Fees ,, Total Paid Initial White — Dept. of Origin a Yellow — Finance • Pink • Applicant aff of HOME -OF PELICAN ISLAND October 27, 2003 Seawinds Funeral Home 735 Fleming Street Sebastian, F132958 Re: Armando Roman Dear Sir: Enclosed is City of Sebastian Certificate Number 1921 for the purchase of Cemetery Lot 27, Block 14, 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, Alm& f - ally A. Maio, CMC City Clerk SAM:ar enclosure