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CITY OF SEBASTIAN
CITY CLERK'S OFFICE 4705
RECEIPT
Name Arad lee hmctersoo -ram f?Y d �rne 40r) 7 11 Cash G ?
Date 'Check# of
No. Amount Paid
001001 208001 Sales Tax
001501 322900 Garage Sales
001501 341920 Copies/Bid Specs.
001501341910 LDC /Code of Ordinances
001501341930 Election Qualifying Fees
601010 343800 Cemetery Lots
Lot(Niche - I n —, Block, —, Unit -,).-
001501 343805 Cemetery Fees 150-00
/J(_JJ Total Paid UU
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Paid by General Receipt No. .0 k . - 6/12/69 ✓lune 10, 1969
............ .... Dated....
List Price $ ... 75 0
. ...... . Maximum No. Burial spaces ...... 1
Discount 7 - 5 00 . 0 ......... Total area in square feet
Net Paid $
Monument Permitted
(Data above this line for City Record only)
Deed 130
Mrs. Lahmion White (Annie Lee)
30x 195# Magnolia St.
Fellsmere, Fla.
Olk, 3n
Lot
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
MOM[ Oi'Elr." 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
Fax: (772) 589 -5570
FUNERAL HOME: .4,yZ>,9 Je S e „1-
ADDRESS:
PHONE #:
(Cheek One)
OPEN BURIAL LOT Lot 7o Block
_OPEN CREMAINS LOT Lot Block
OPEN COLUMBARIUM NICHE Niche Block
BURIAL DATE AND SERVICE TIME
3t> Unit
Unit
Unit
W
7 /M`z> 1.,0Q10. ^
FOR DECEASED: ^WWA(�e ,4,
Name
NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE:
(Must provide proper documentation of ownership)
A/ . AA
Name 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 authorize opening of same
NAME AND SIGNATURE OF LICENSED FUNERAL DIRECTOR.
Name Signature Date
------------------------------------------------------------------------------------------------------------------------ - - - - --
Cemetery Sexton Certification:
1 certify that I have checked the ownership inforn-iation by viewing
with Clerk's office and that all fees have been paid
�/� a - xl"4 C-;� - io-
e etery textdn le Date
the owner's deed and confirming
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.