HomeMy WebLinkAbout2-47-14Name 1 I- CAY1 -i
Unit 2
Block
Lot l `i
Date of Mark -out �O
Lo
Date of Burial 3 7 Time #C vy\ C he . �f (✓�
Name of Funeral Home
Authorized by
CITY OF SEBASTIAN
FINANCE DEPARTMENT RECEIPT C �' 5
Name'CilQYY1Cr i10'ti6lCt �lC,t' -�►❑ Cash
Date CO'll iy a<heck #_13 9
001001 208001
001001 220000
001501 362100
001501 362150
450010 369900
001501 329500
Sales Tax
Security Deposit -
Taxable Rent -
Non- Taxable Rent -
Airport Badge
Alarm Permits
❑ Credit
Amount Paid
001001218010 CobraServe
001501 354100 Code Enforcement Fines
001501 347557 Community Center Revenue
001501341920 Copies
001501 369900 Miscellaneous Revenue
001501 359000 Other Fines /Forfeitures
001501 351140 Parking Citation
001501 342100 Police Security Services
Gm4mr, FN 150.va
Total Paid
Initials
White - Dept. of Origin • Yellow - Finance • Pink - Applicant
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
C00
NOME OF PELICAN ISLAND
For information contact:
Kip Kelso - Cemetery Sexton
Sebastian Municipal Cemetery
(772) 589 -2545
City Clerk's Office
City Hall, 1225 Main Street
Sebastian, FL 32958
Office (772) 388 -8215 or 388 -8214
FUNERAL HOME:
ADDRESS: ��JS S TXtV \
ft !EM tY.
SO%S -�Ck
A , PL
PHONE #: ` sloli-1013�
(Check One)
_OPEN BURIAL LOT
Lot_
Block Lj1
Unit �^
OPEN CREMAINS LOT
Lot
Block
Unit
OPEN COLUMBARIUM NICHE
Niche
Block
Unit
BURIAL DATE AND SERVICE TIME:
``___,,��,,,,
51 �
N S
► � 1�
E W
I TT50
FOR DECEASED: �<QSNCeSCCU. C7lt 4Cx1\ Cpl\ -AS
Name
E SIGNATURE OF LOT OWNER OR EPRES TIVE:
(I vide proper ume. ion of owners ip)
1
Name Si re
9 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 authorize opening of same.
Cemetery Sexton Certification:
I certify that I have checked the ownership information by viewing the owner's deed and confirming
with Clerk's office ano th all fees have been paid:
X�� Q I�V,4,0 /-;� r 16zl�
CerAetiry 1jext&n Dat
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.
State of Florida, Department of Health, Bureau of Vital Statistics
BURIAL TRANSIT PERMIT
HEALM DATE PRINTED: June 11, 2014 TRACKING NUMBER: 2014084923
1. DECEDENT INFORMATION
Name of Deceased Date of Death
FRANCESCA GIOVENI COUSINS June 9, 2014
Place of Death - County City, Town or Location Name of facility, or street address if not a facility
OSCEOLA KISSIMMEE OSCEOLA REGIONAL MEDICAL CTR
Name and Address of Funeral Home /Direct Disposal Establishment Fla. Lic. No. /Reg. No. Phone Number
SEAWINDS FUNERAL HOME F073380 F073380 (772) 589 -1933
735 SOUTH FLEMING STREET
SEBASTIAN, FLORIDA, 32958
Funeral Director /Direct Disposer Fla. Lic. No. /Reg. No.
RACHELPETRASEK F052116
2. BURIAL - TRANSIT PERMIT
The Florida Department of Health, Bureau of Vital Statistics
hereby grants permission to dispose of this body in accordance with Chapter 382, Florida Statutes.
Permit Number: 2014- FO73380 -5143
Q G / J r Date Issued: June 10, 2014
`c.
Meade Grigg, State Registrar
3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL -AT -SEA, or HOSPITAL DISPOSITION
Authorization given by Medical Examiner District Approval Number:
4. CEMETERY OR CREMATORY
Place of Disposition: SEBASTIAN CEMETERY
Method of Disposition: BURIAL Date of Disposition:
EDRS maintains all statutorily required information regarding the death record and related
burial transit permit, therefore, returning the permit to the county health department is no
longer required.
If the Place of Final Disposition wishes to retain the copy of the permit for their file they may do so.
DH 326E, 10/12
64V- 1.011, Florida Administrative Code
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THE SEBASTIAN CEMETERY
City of Sebastian
Sebastian, Florida
,r RECEIPT IS HEREBY ACKNOWLEDGED OF THE SUM OF:
31
-• IMPEVIEZIF ,--
ZIP 4P
.411. 3 z in
on this ay of 1985 for the purchase of the following
described Cemetery Lot(W upon . he terms and conditions as stated herein:
Description of Property: ,/
Cemetery Lot (s) # IA %//V Block# T 7 Unit#
Purchase Price:C A- *-- -Dollars ($
i
Terms and'conditions of sale:
This contract shall be binding u n both parties, the seller and the purchaser, when
approved by the owner.of the propp&rty above described.
I, or we, agree to purchase the above described property on the terms and conditions
stated in the foregoing instrument:
The City of Sebastian agrees to sell the above mentioned property to the above named
purchaser(s) on the terms and conditions stated in the above instrument.
• City of SaAaktian
Witness