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Home My WebLink About4-14-34O aTy of SEBASTIAN HOME OF PELICAN ISLAND Certificate No. 2004 C31TY'Of SEBASTIAN Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Dana Gorecki 1382 Starboard Street, Sebastian, F1 32958 (name) (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 _14_ Lot 34_ 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 31st day of January, 2005. Y0 SEB IAN, FLORIDA ATT r f 5rrenoe oore S A. Maio, MMC City Manager City Clerk Name !✓ b DF f 5 Gr0/'' G 1 �� X r`'S Unit /Al Lot / Date of Mark -out /A( � A 5 Date of Burial � / � �' / 5~ Time Name of Fune Authorized by r an awl" SEBA-STKN 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 �i9i✓� o,Q FcK• Name(s) AdAess _ Area Code & Phone - Number Residence Address of Intended Occupant if Other Than Purchaser Office Use Only Receipt_is acknowledged in the sum of: •�� Dollars ($ d d • d d_) on this day of , 20��or the purchase of the following described Cemetery Lot( nd /or Nic s). Unit , Block , Lot(s) 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 W O H Circle One Vase and Ring for Niches (cost) Interment Disinterment Signature of Purchaser City of Sebastia T L $ Service fees are to be paid at time of need only l: \W W- DATA \Ms- CemeterylRECE I PT.doc FLORIDA DEPARTMENT OF '� — � �� y HEALT / State of Florida, Department of Health, Vital Statistics / APPLICATION FOR BURIAL - TRANSIT PERMIT A. (TYPE) 1. Name of First Middle Last Date Month Day Year Deceased of Dolores J . Gorecki Death January 21, 2005 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 Samuel D. Watkin It, M.D. 1265 36th Street Medical Examiner 1 0 jPhysician Vero Beach. 3. Name of Funeral Home /Direet-BispoS 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. ❑ The medical certification has been completed and signed. A completed certificate of death accompanies this Appropriate application. Box b. Kathy was contacted on 1/24/05 He /she verified that this death was from natural causes, that there was no accident nor other external cause of death, and that Dr. Watkins 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 coificationAXause of death within 72 hours. i. Funeral Director/ n F.E. No. /Reg. No. Date Signed 1862 1/21/05 3. BURIAL - TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No. 1228 -05 -0037 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. *ef'— -4 Date Date Certificate Subregistrar Signature , i ,� M �N..�,Q Issued: 1/21/05 Due: 1/26/05 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. CEMETERY OR CREMATORY Method of Disposition: Place of Disposition Sebastian Cemetery 14BURIAL STORAGE Date of Disposition �� 6 / CREMATION OTHER (Specify) Signature of Sexton or Person -in- Charge 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 ;lock Number 5740- 000- 0326 -2) Pink: Local Registrar CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT m Cash ae 06W eck #i7�9d 9 Amount Paid 1001208001 Sales Tax 1501322900 Garage Sales 1501341920 Copies/Bid Specs. 1501341910 LDC /Code of Ordinances 1 1501 341930 1 11010 343800 1 11501343805 Election Qualifying Fees Cemetery Lots LoVNichNj,V-- Block rt Unit Cemetery Fees �sd I W1—ze—?-- Total lde7-,M o In lga e ' White - Dept. of Origin • Yellow - Finance a Pink - Applicant ;Loa� L rru.0 4 , � � � 14-, Lo T 3 �F M a.,,.-1 c l .,Q -6 , ►fit- CI�/r'1 C.. 13 k 2 ShXA bed St . Z-L dLA a., , FC 32 9.rX «11 m HOME Of PELICAN ISLAND 1225 Main Street, Sebastian, F132958 Telephone (772) 589 -5330 — Fax (772) 589 -5570 January 31, 2005 Ms. Dana Gorecki 1382 Starboard Street Sebastian, Fl 32958 Dear Ms. Gorecki: Enclosed is City of Sebastian Certificate 2004 for the purchase of Cemetery Lot 34, 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. Sin ly, Sally A. aio, MMC City Clerk SAM:ar enclosure