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Certificate # 1965
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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:
Adam Brustowicz
(name)
84I Beard Avenue, Sebastian, Fl 32958
(address)
in and for consideration of the sum of 350.00 has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plots:
Unit _ 4_ Block _13_, Niches_ 11B_
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 16th day of June, 2004
City Manager
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S A. Maio, CMC
City Clerk
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Name
Unit_
Block
Lot /l '` �
Date of
Date of Burial ��f�� Time f �:� p� �
Name of. Funeral Home ����'�:k%� ?'
Authorized by �_ ' ' '
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�1Y' OF
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HQN[E +E3F PELICAN iSiuAND
June 17, 2004
Mr. Adam Brustowicz
841 Beard Avenue
Sebastian, Fl 32958
Dear Mr. Brustowicz:
Enclosed is City of Sebastian Certificate Number 1965 for the purchase of Cemetery Lots 11B,
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.
Sin r�ly, �
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Sally A. 'o, CMC
City Clerk
SAM:ar
enclosure
CITY OF SEBASTIAN
CITY CLERK'S OFFICE � � 9 �
n�ne�eT
No. �
001001 208001
001501 322900
001501 341920
001501 341910
001501 341930
601010 343800
001501 343805
Sales Tax
Garage Sales
CopiesBid Specs.
LDCICode of Ordinances
Election Qualifying Fees
Cemetery Lots ���--`--� ��
LoUNiche ��'� , Block �, Unit �
Cemetery Fees � OD
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Total Paid � v` �
White — Dept. of Origin • Yeilow — Finance • Pink • Applicant
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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
ra#e regulations, residence of purchaser or person for whom lot is intended for interment must be
provided at time of purchase �
Aaaress
77.2• 3a�- `7�3:
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Receipt is acknowledged in the sum of:
Dollars ($ 350� ° ► �
on this l day of ��,� , 20 0. for the purchase of the following
described Cemetery Lot(s) and/or Niche{s).
Unit � , Block �� , Lot(s) I �� Niche(s)
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for use in accordance with the conditions, ordinances, resolutions, rules and regulations
prescu�ed therefore by the City of Sebastian.
Additiona! Fees paid a# time of purchase:
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Corner Markers (set of 4-$20) Opening 8� Closing '� 5 p W O H
Circle One
Vase and Ring for Niches (cast) Interment a8. d D Disintertnent
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Sig re of Purchaser �r of Sebastian
Service fees are #o be paid at time of need only
1:1W W-DATA1Ms-CemeterylRECEIPT.doc
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