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HomeMy WebLinkAbout4-12-21Certificate No. 2260 CITY OF SEBASTIAN Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Charles Burke 9605 Mockingbird Lane, Micco, FL 32976 (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 lot: Unit 4, Block 12, Lot 21 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 4t" day of June, 2010. CITY OF SEBASTIAN, FLORIDA ATTEST: 4. Al Minner City Manager % . ®� Sally Maio, MMC City Clerk Name �f IeIiG,�. /VUIe Unit Block L Lot zL Date of Mark -out Date of Burial a Time Name of Funeral Home ----5 Z gkq Authorized 9 'J °° o °O o °O °O 00 z o v a z d ° °° n A 9 7 -1 o 0 o_ 0 0 0 e. _ A A ? A A N O ? Lam. d rn 0. 0- Cl O Cr O fD W O <D O t0 N O [ND O O O O t 1 N S m m� n 10 C I o o w m , D m Cl) x T I r C , O . co �\ o w o N 9 A FT O �A -< 1 d I �pT �mr ° y a) mom f � �yD -40 t V/ C ^, _ IN m of m z . I LL V d =r CL 46 a c c 9 'J n DO m 7 -1 ? rn —t , D m ` © H I t IN m of LL V Tl 9 'J FLORIDA DDE APARTTTMENNTT O`F L 1 A. (TYPE) State of Florida, Department of Health, Vital Statistics APPLICATION FOR BURIAL - TRANSIT PERMIT 1. Name of First Middle Last Date Month Day Year Deceased of Grace Hamilton Burke Death 06/02/2010 2. Place of Death City, Town or Location Name of (If neither, give street address) County Hosp. or Brevard Palm Bay Inst. Palms Rehab and Healthcare Center 3. Name of Medical Address Phone Number Certifier Paul R. Biggs 5405 Babcock Street NE Medical Examiner X hysician Palm Bay, FI 32905 321/725-4500 4. Name of Funeral Home /Direct Disposal Address Fla. Lic. No. /Reg. No. Phone No. (Area Code) Establishment Strunk Funeral 1623 N. Central Avenue Homes & Crematory Sebastian, FL 32958 F041870 772/589-1000 5. Check a. U The medical certification has been completed and signed. A completed certificate of death accompanies this Appropriate application. Box b. ® Christine was contacted on June 2, 2010 He /she verified that this death was from natural causes, that there was no accident nor other external cause of death, and that Paul R. Biggs, M.D. will complete and sign the medical certification of cause of death within 72 hours. C. ❑ was contacted on He /she verified that Medical Examiner, will complete and sign the medical rtificaf use of death within 72 hours. 5. Funeral Director/ gn re F.E. No. /Reg. No. Date Signed F044048 06/04/2010 3. BURIAL - TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No. 1228 -10 -0504 nA five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has been contacted by the funeral director and will not be able to complete the medical certification of cause -of -death section of the death certificate within 72 hours. F] No extension of time fo �the th ce i nt e—Ris been requested. or Date Date Certificate r ignature Issued: 06/02/2010 Dye: 06/06/2010 Approval Number: AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA Date Medical Examiner, , gave authorization by telephone to Funeral Director /Direct Disposer. Date The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting period of 48 hours after death is required for all cremations. Method of Disposition: 11 BURIAL ❑CREMATION Signature of Sexton or Person -in- Charge STORAGE DOTHER (Specify) CEMETERY OR CREMATORY r-- Place of Disposition Date of Disposition -his permit must be endorsed by the Sexton or person -in- charge (or by the Funeral Director /Direct Disposer when there is no Sexton) and returnea vithin 10 days to the local County Health Department in the county where disposition occurred. Distribution: White: Cemetery or Crematory ,H 326, 8/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer hock Number: 5740- 000 -0326 -2) Pink: Local Registrar RrY kJ %v P.P. SAS _ 1 l V (} Y Z�% HOME OF PELICAN ISLAND City of Sebastian Municipal Cemetery Purchase Receipt 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 whom lot is intended for interment must be provided at time of purchase. LKo-r leS Burk e, Name(s) 5 Mock IV7 Address J C-7 7 2) &64 - 3&&6; Area Code & Phone Number M i ew FL, 32 q 7 Name & Residence Address dq tended Occupar&if Other Than Purchaser OFFICE USE ONLY Receipt is acknowledged in the sum of: ollars ($ 02. 00.00 ) on this. day of , 20 �O for the purchase of the following described Cemetery Lot(s) and /or Nich s). Unit 4 , Block 12- , Lot(s) 21 Niches 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) Vase and Ring for Niches (cost) Temporary Marker Preparation & Installation Opening & Closing t J�� . U / W O H Circle One Interment Disinterment TOTAL $ l 5L .00 1 n 1 Signature of Purchaser 16ty of Sebastian The following documents were provided as Proof of Residency: 1 \VVVV- DATA \Ms- CemeteN\RECEIPT.doc I I and 06/04/2010 12:15 7725892583 STRUNK FUNERAL HOME Jun 04 2010 10:45RM COS CEMETERY 77222289927 FUNERAL DIRECTOR'S REQUEST TO CITY OF'l1BAZITIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY SE wry a ► ,� o For Into►n►eli0n oemtoot: KIp Kelso - Cemetery Sexton 9ebe011on Munklpal Cemetery r7n) ee0-24146 1 CIly CNrk tr 011ke Cuy Hal, 1226 M.rn $frog( woes(.(, OWL 32980 Ol11ce (??V 300.0215 or 300.921-0 Peet: (172) 509 -5570 FUNERAL HOME: Strunk Funeral Homes S Crematory ADOREUS: _ 1623 1 -_ Central Avenue, Sebastian, FL 32958 PHONE X: 722/589 -1000 (Check One) _ —OPEN BURIAL LOT Lot 81ock Unit , _.OPEN CREMAIN9 LOT Lo look Unit ---,OPEN COLUMBARIUM NICHE Nlch• Block mm ""Unit BURIAL DATE AND SERVICE TIME: _Amdy. 61-1/2010 - 12:00 Noun FOR DECEASED, Hamilton Burke rvsrria PAGE 01 P.1 NAME AND 31ONATURE OP LOT OWNER OR REPRESENTATIVE: (Must Pprovide proper documentation of ownerehi ) Z L9 arnd pate I certify that I have determined the ownershlo Of the above deeerlbed vice that all silo (ears and adMIN911retive fees hove been peld and authorize opening of Santo NAME AND SIGNATURE OF LICENSE=D FUNERAL, DIRECTOR. ,ljlliam B. Whittaker u l 06/0412010 Name 9198sture ==4 Date ...................................-............. ...................----.............._...------- ........................... Cemetery Sexton Conillention: certify that ; hove eheeked the ownership information by viewing the owner's deed and confirming with Cierk'a otfiev and that all tees nave been paid r Ja m ery SA 104AI Dote This i4n,i to be provided to Clerk's Office by Sexton for permanent record upon compietron. 06/25/2011 W54 FKjg 24 2011 10:33AM I HP LASERJET FAX Clf.y Or 5f jI4 IitI l br•n.ill+lu Cer11e1fPr•• Pb. lf- It7711 SY-► 194E 1.0. N 117111 174 . M? 10036 P.001/1004 P,2 'Yule 1 'rMNb #or Igfur11r11k�nyt purpo►t+ retlesr11i11R Alutle wail YI Scllssllan (*cnivlcr► . NO,, ; Thlb 11 far• SIn1119 " "ark"" "floor 7 Q. IQ over = h•( wer t A. 1 %a I-wrud NVIIJ611"n ) M►,.e reoura Iv C Cdty Of Set?ellley pry Mix tiubeRlis" Cenwlery 1011 Nor% Prnlral 4,,c. httur♦4ulhln Uu�re F>i 3 300 11 y .►IlenHr111 P y y • 2- C7 d L.0081 DeseNp /don : 4 Unit ; T _ 010c. : ... tot . 21 .,...T._......._._.. square pt ✓ �1 T - -- Checked By IIATF By Exempla STRUNK FUNERAL HOME i CREMATURY 1623 No. Central Ave. SEBASTIAN, FL 32955 on) 589.1000 �•afflltaf Van:te A gronze ?062837043 071312011 09:45 0809 P.001/041 �� .0 c IiAv k=4 cl CA i c J �:.. c;z ,� � y ZO. % OOO/ZOO d 9COOI Ir -4 ui Q L4 3: w z OVS0 ILOZ/SZ/80 04/29/2015 13: 13 #4393 P. 001/001 nug c:t cUt 1 1U; 3 3F)M HP LASERJET FAX a _ • 4 4,1e A tVALSVIIi- Cil Orr y of Se r'a,rt rrrri Srflasiiiu(:' Ilk!arr..• Pi.M 107)1 Sp'+ 1'4% N 1417:I IZA•on? Mule : rAt►II for IP(Urrrtllt0h4 $purpo►r►rcgttardlni Ai„nur►rat% VI Sc1U,stt:tn t'citl+•Icn NON: '('Ata h fur Singly 1Isrk1--r«ander 2 11..ti aver:fit Wirt')A,I%a Num) ) ur IMev.r return Ir City of Srbi7+laDry Mix K.rhpillan cemetery )9Z1 !r Ar1Il renlr01 �1►e )•ItuuQ:lll.ttl ry Ertl • • AIlcnllte 1< ✓ �IZ'rynSlArlcrt Srslclrl 17C1\1--C 'd hob /( o by la S/Zp/7 i5— . .. . .TWIT+ I i :111 J She': Ua PLP-1 � I +laity 574 0/4 Harm b 0110 : HIS 0.0.8. A° 12 D.O.O. Logs)OesorlpIllon 4)49-1—. rinfr . Hi we KIEV alk. : • / / t.�. Lot Square Ft. ; Approved by • -_ C11e000140 : • 'M•1'It • '' a • Er ample ; STRUNK FUNERAL HOME & CREMATORY • 1625 No. Central Ave. SEBASTIAN, FL. 32958 (772) 589-1000