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HOME OF PELICAN ISLAND
Certificate No. 2221
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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:
James and/or Patricia Downs 1554 Addie St., Sebastian, FL 32958
(name) (address)
In and for consideration of the sum of $2,000.00 is entitled to full interment
rights in the Sebastian Municipal Cemetery for the following lots:
Unit 4 Block 10 Lots 29 & 30
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 29th day of May, 2009.
EBASTIAN, FLORIDA
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` AI Minner
City Manager
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Sall A. Maio, MMC
City Clerk
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Unit�
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Lot X 7
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Date of Burial l� ✓���' Time Q:��' C
Name of Funeral Home s��-:� K��
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JAMES H. DOWNS
Mr. James H. Downs, 75, died January 2, 2013 at Grace Healthcare in Vero
Beach. He was born July 17, 1937 in Davenport, lowa and lived in
Sebastian for six years coming from Port St. Lucie, FL. He was a
superintendent with the Caterpillar Equipment Company in Davenport,
lowa for over 30 years. He was a member of the Southeast Rods and
Customs, the Renegade Cruisers, the Grand Prix Chapter and the GMC
Tr�ck Chapter.
Survivors include his wife of 56 years, Patricia Downs of Sebastian, sons
James E. Downs of Davenport, lowa and Brian Downs of Summerville,
South Carolina, four grandchildren and one great-grandchild.
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING !N SEBASTIAN MUNICIPAL CEMETERY
una
HOAff OF iELICAN ISIN�D
For information contact:
Kip Kelsa - Cemefery Seuton
Sebastian Municipal Cemetery
(772J b89-2545
City Clerk's Office
City Hall, 1225 Main Street
Sebastian, FL 32958
Office (772) 388-8215 or 388-8214
Fax: (772) 589-5570
FUNERAL HOME: �.%��� � � �� � �-�Z � �-- '�[ � � �-
ADDRESS: �/ % � �� C'C>�'�J�i2�-� d�-I%�
PHONE #: ,� B � � l ���
�(Che k One)
OPEN BU RIAL LOT Lot Z�o�.3C Block _� Unit �_
OPEN CREMAINS LOT Lot Block Unit
OPEN COLUMBARIUM N1CHE Niche Block Unit
N S—� E W
BURIAL DATE AND SERVICE TIME: ��2(1 cC� �(��/� //`7 /�
FOR DECEASED: �S �l'Jr1�t� s t� �� l� �/ii S
Name
NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE:
(Must vide proper documentation of ownership)
_. ... .. , . � .
/� i ���� (,�-) �!M �-2. ✓rn,� 1 y l3
Name Signature D te
I certify that I have determined the ownership of the above described site, that all site fees and
administrative fees have been paid and authorize opening of same.
NAME AND SIGNATURE OF LICENSED FUNE DIRECTOR:
r oT�z v�: �?/1 �-2-✓ «ti � l2 �'� j`� ��
Name ignature D te
Cemetery Sexton Certification:
I certify that I have checked the ownership inforrnation by viewing the owner's deed and confirming
with Clerk's office and that all fees have been paid:
. � � ,
Ceme ry exto Date
This form to be pro�ided to Clerk's Office by Sexton for permanent record upon cornpletion.
_ -�
E�,NttD�DH'rtJ[C4i�iDF • ,� $tate of Florlda, Department of Health, Bureau of Vital Statistics
HEAL'� BURIAL TRANSIT PERMIT
DA'i� PRINTED: January 4, 2013 TRACKIN6 NUMBER: 2013001251
� • DECEOENT INFORMATION
Name of Decea9ed Dda o( Depth
JAMES A OOWNS January 2, 2013
Place of Death . Cqu+�ty Clty, Town or Location Name of fecllity, or st1Y�t AOtl�Yts iF not a faclllty
INDIAN RIVER VERO BEACH GRACE REHABIL17A7i(7N C�NTER
Name end ApdYOS! of Funeral HomelDll'ott Disposal Eatabllyhmont Fla. Lic. No.lROfl. No. Ph0111 Num6Yr
STRUNK FUNERAL HQM�. SEBASTIAN F041870 F041870 �772) 588•1000
1623 N CENT�p,L AVE
SEBASTIAN, FLORIDA, 32958
Funeral DlreCtorlpiract Dlspoaer
TIMOTHY W. MAkViN
Fla• LiC. No.IRpg. No.
Fo22786
�� BURIa� - TRANSIT PERM�T
The Florida Department of Health, Bureau of Vi�� Statistics
hereby grant,s perml�sion to dispose of thls body in accordance with Chapter 382, Fiorida Statutes.
Psrmit Numbar: i013-FOq1870•5002
, G� �j, r' Dato Issued: January 4, 24t3
J �
Meade Grfgg, Stato Reglatnr
3. AUTHORIZATIdN for CRE'MA710N, DISSEC7IQN, BURIAL-A7-SEA, or HOSPITAL DI$PO$ITION
Authonzatlpn given by ly�ed�cd� Examiner DistriCt
approval Number:
4' CEMETERY OR CREMATQRY
PIaG6 Of DISpOSitiOfl: $EBASTIqN CEMET�Ry
Method of D�ypoaltion: BuRiq� � .
Data of Dlapoaitlon;
s gnat ro of a ton Or perEOn-in harge (or by the funaral dlrectorldirect dlapo9er when there is no s�xton)
bM 326�, 7j��
64V-1.011, Flaida Adminiatra�ive Cpde
Cf1Y OF
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Ht71'VlE JF PELICAhI ISEAC�IG
1225 Main Street, Sebastian, FL 32958
Telephone (772) 589-5330 — Fax (772) 589-5570
June 2, 2009
Mr. and Mrs. James Downs
1554 Addie Street
Sebastian, FL 32958
RE.• Interment Rights to Unit 4, Block 10, Lots 29 & 30 Sebastian Cemetery
Dear Mr. & Mrs. Downs:
Enclosed is City of Sebastian Certificate 2221 entitling you to full interment rights in
Unit 4, Block 10, Lots 29 & 30.
Also enclosed is a copy of the Rules and Regulations governing the Sebastian Municipal
Cemetery.
If you have any questions, please contact our office.
Sincerely, A
�-��� ; ' ���..�',,
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Sally A. Maip, MMC ���'
City Clerk �
SAM:dwc
enclosures
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Ht?iYIE C7F PEi.FCAN ESt,APdCr
City of Sebastian Municipal Cemetery Purchase Receipt
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To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate
regulations, proof of City residency of purchaser or person for wh m lot is intended for interment must
be provided at time of purchase. „ , (, �
Name(s)
Address
Area Code & Pl�one Number
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Name & Residence Ad$ress of Intended Occupant if Other Than Purchaser
OFFICE USE ONLY
Receipt is acknowledged in the sum of:
�. . '. �i,� 1�
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)
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)
Temporary Marker Preparation & Installation
✓
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' nature of Purchaser
Interment
/W O H
Circle One
Disinterment
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Sebastian
The following documents were provided as Proof of
cces�aenc :
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CITY OF SEBASTIAN
CITY CLERK'S OFFICE 4 5 5 6
RECEIPT
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Name ( �'�J ( T ��� t 1\ ���i,t '_j`�j� ❑ Cash
Date� C �' '.�. �,
� ; �Check #-�����
No. '��,,� .
Amount Paid
001001 208001 Sales Tax
001501322900 Garage Sales
001501341920 Copiesl6id Specs.
001501341910 LDC/Code of Ordinances
00150134193p Election Qualifying Fees
601010 343800 Cemetery Lots � � �� � �'t'
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LoUNich�`� Block �i Unit �
001501 343805 Cemetery Fees
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',-_�I ti�ials
Totai Paid ���—
White - Dept. of Origin • Yellow - finance • Pink - Applicant