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Home My WebLink About4-14-28i O O i aR' of SjE1SASTtkN HOME OF PELICAN ISLAND Certificate # 1954 CITYOW SEBASTIAN Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Sherwood A. & Janice W. Innis 431 Copley Terrace ,Sebastian, Fl 32958 (name) (address) in and for consideration of the sum of $1,400.00 has purchased and is entitled to full interment rights in the Sebastian Municipal Cemetery for the following plot: Unit _ 4_ Block _14_, Lot(s)— 28 & 29 _. of the Sebastian Municipal Cemetery, as maintained on file in the records of the City Clerk for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. CONVEYED THIS 8th day of April 2004. YSEB TI AN, FLORIDA A7T: `ence oore y A. Maio, CMC tv-- ManaLer City Clerk OO MR Name Unit Block Lot Date of Mark-out Date of Burial Time Name of Funeral Home Authorized by LE Vb 74 .s, Co co� f DEPARTMENT OF i7 A. (TYPE) State of Florida, Department of Health, Vital Statistics APPLICATION FOR BURIAL - TRANSIT PERMIT on) 1. Name of First Middle Last Date Month 44 Day Year Deceased of April 3 200$ Sherwood Alexander Innis Death 2. Place of Death City, Town or Location Name of (If neither, give street address) County Hosp. or Indian River Sebastian Inst. 431 Coply Terrace 3. Name of Medical Address Phone Number Certifier Pedro Espat, D.0 8005 Bay Street, #3 Medical Examiner Physician Sebastian, FL 772- 589 -5600 4. Name of Funeral Home /gimat Wispesel —► Address Fla. Lic. No. /Reg. No. Phone No. (Area Code) Establishment 1623 N. Central Ave. Strunk Funeral Home Sebastian, FL 1228 772- 589 -1000 5. Check a. U The medical certification has been completed and signed. A completed certificate of death accompanies this Appropriate application. Box b. Christy was contacted on 415/04 He /she verified that this death was from natural causes, that there was no accident nor other external cause of death, and that Dr. Espat will complete and sign the medical certification of cause of death within 72 hours. C. A was contacted on He /she verified that Medical Examiner, will complete and sign the medic c ificati n of Wse of death within 72 hours. 5. Funeral Director/ igna re F.E. No. /Reg. No. Date Signed � aretspvs>sry � T$62 4/3/04 3. BURIAL - TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No. 1228 -04 -0157 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. 6 +� �L, Date Date Certificate Subregistrar Signature Issued: 4/3/04 Due: 4/8/04 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. A waiting period of 48 hours after death is required for all cremations. D. CEMETERY OR CREMATORY Method of Disposition: Place of Disposition Sebastian Cemetery BURIAL STORAGE Date of Disposition Y/e /Q 'Y CREMATION Signature of Sexton or Person -in- Charge I 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 nrithin 10 days to the local County Health Department In the county where disposition occurred. Distribution: White: Cemetery or Crematory )H 326, 8197 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer Stock Number 5740- 000 - 0326 -2) Pink: Local Registrar mor �9s SEISAST%N Y 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 time of purchase Area Code & Phone Number Residence Address of Intended Occupant if Other Than Purchaser Office Use Only Receipt is acknowledged in the sum of: i av Dollars ($ ed - Od ) on this gZe day of , 200 for the purchase of the following described Cemetery Lots) d /or Niche(s). Unit _, Block , Lot(s) We P 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 '� '5— 40O 6'.) O H Circle One Vase and Ring for Niches (cost) Interment Disinterment Signature of Purchaser ity of Sebastian TOTAL $/- �%� d d Service fees are to be paid at time of need only I: \W W- DATA \Ms- Cemetery\RECEI PT.doc CITY OF SEBASTIAN CITY CLERK'S OFFICE 2701 RECEIPT Na ❑ Cash Date No. Amount Paid 001001 208001 Sales Tax 001501 322900 Garage Sales 001501341920 Copies/Bid Specs. 001501 341910 LDC /Code of Ordinances 001501 341930 601010 343800 Election Qualifying Fees Cemetery Lots �� • �d Lot/Nichbormet? Block Unit 001501 343805 Cemetery .Fees (/r 01 7'- Total PaiH Initials White - Dept. of Origin • Yellow - Finance • Pink - Applicant CITY OF SVsAsir� 71 HOME OF PELICAN ISLAND April 8, 2004 Mrs. Janice Innis 431 Copley Terrace Sebastian, F1 32958 Dear Mrs. Innis: Enclosed is City of Sebastian Certificate Number 1954 for the purchase of Cemetery Lots 28 & 29, 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, Sally A. Maio, CMC City Clerk SAM:ar enclosure