HomeMy WebLinkAbout3-COL-30DsName
Unit
Block
Lot �.
Date of Mark -out C
Date of Burial �,Q / �' Time 6fl �
Name of Funeral Home
Authorized by
CITY OF SEBASTIAN 10410
ADMINISTRATIVE SERVICES RECEIPT
Name (&Q0 O Cash q
Date //3011/7 Check# 10' /3
❑ Credit
Amount Paid
001001 208001 Sales Tax
001001 220000 Security Deposit
001501 362100 Taxable Rent
001501 362150 Non -Taxable Rent
450010 369900 Airport Badge
001001218010 CobraServe
001501 354100 Code Enforcement Fines
001501 347557 Community Center Revenue
001501341920 Copies
001501 351140 Parking Citation
001501 342100 Police Security Services
001501 329200 Site Plan Review
001501 329300 Subdivision/Plat Review
001501 329100 Zoning Fees
(301 sot 3 4a5 OAC
Un11T -I 1�1 0,3L Lor 3OD$
Total Ad
Initials
Security Dep Held -Amount $ Check #
White - Dept. of Origin • Yellow - Admin. Svcs. • Pink - Applicant
Funeral Director's Request to City of Sebastian for Burial Opening in Sebastian
Municipal Cemetery
Contact Information:
Kip Kelso, Cemetery Sexton
Sebastian Municipal Cemetery
Phone (772) 589-2545
Fax (772) 228-9927
City Clerk's Office
Cathy Testa
City Hall, 1225 Main Street
Sebastian, FL 32958
Phone (772) 388-8209
ctesta(c)citvofsebastian.org
(Check)
Open Burial Lot
Lot_
Block_
Unit_
Open Cremains Lot
Lot_
Block_
Unit_
x Open Columbarium Niche
Niche 30Ds
Block C L
Unit 3
(Circle)
N
E W
29
Burial Date and Service Time: 1%'?6 )7
o-' )x!30 af`n
Deceased Name: Gloria Cascio
Name and Signature of Lot Owner or Representative:
Must provide proper document ipn of =own , 5 ,
h Von provide
to �/ �)W- f�
Print Name y Signature Date
I certify that I have determined the ownership of the above described site that all site fees and
administrative fees have been paid and authorized opening of same.
Name and Signature of Licensed Funeral Director:
Print Name
Signature
Date
I certify that I have checked the ownership information by viewing the owner's deed and confirming with
Clerk's Office and that all fees have been paid:
Cemetery Sexton Certification:
3D 7-
e ete exton Date
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.