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HOME OF PELIGN ISLAND
Certificate # 1950
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Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Eugene Dernbach
(name)
757 Forster Avenue, Sebastian, FI 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 13 , Lot(s)_9B & l OB_
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 19th day of March, 2004.
DA ATTES�'�.
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Sally .1Vlaio, CMC
City Clerk
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CE1Y OF
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HOME OF PE41GN 15I.�►ND
March 22, 2004
Eugene Dernbach
757 Forster Avenue
Sebastian, Fl 32958
Dear Mr. Dembach:
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Enclosed is City of Sebastian Certificate Number 1950 for the purchase of Cemetery Lots 9B &
l OB, Block 13, 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.
Sinc ely,
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Sally A. o, CMC
City Clerk
SAM:ar
enclosure
S�BASTI�
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HOME OF PELiCAN ISWVD
City of Sebastian Municipal Cemetery
Purchase Receipt
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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
�!l G�t%" �����y�
Name(s)
�s� �oR�,� AvE,��� . oS'E���f ��. �.c. 3��.��
Address
77,Z - �6� -2ss'3
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
O�ce Use On/y
is acknoyrledged in the sum of:
/ D �
Dollars ($ d • � d' )
on this � day of ���_, 20�for the purchase of the following
described Cemetery Lot(s) and/or Niche(s).
Unit �, Block �.� , Lot(s) Niche(s) ��� �'- /o �
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-$20) Opening & Closing
Vase and Ring for Niches (cost) Interment
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Si ture of P- aser
W O H
Circle One
Disinterment
TOTB�$'�%d o . o 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 oFF��E . 2 6 4 3
RECEIPT
Nam� �%G / E ❑ Cash
Date eck #_1�
No. Amount Paid '
001001208001 Sales Tax
001501 322900 Garage Sales
001501341920 Cop'reslBid Specs.
001501 341910 LDGCode of Ordinances '
001501 341930 Election �ualihring Fees
601010 343800 Cemetery Lots � �B � � ''
LoUNich���� Block� � . Unit �
001501 343805 Cemetery Fees
Total PaiQ I',
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nitials '
White - Dept. of Oripin • Yellow - Finance • Pink - Applicant
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