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Home My WebLink About4-04-20CITY OF SEBASTIAN, FLORIDA Al Minner City Manager CITY OF HOME OF PELICAN ISLAND CITY OF SEB STIAN Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Ledora /or Kenyatta McCombs 121 Bristol Street Sebastian, FL 32958 Certificate No. 2290 In and for consideration of the sum of $1,000.00 is entitled to full interment rights in the Sebastian Municipal Cemetery for the following lot: Unit 4, Block 4, Lot 20 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 23 day of March, 2011. ATTEST: Sally A. Maio, MMC City Clerk Name No. 001001 208001 001501 322900 001501341920 001501 341910 001501 341930 601010 343800 001501 343805 Date 3 ,a3-0 Name 4././1si i ft /I ep ∎ofes- 71( 8 Unit Block Lot AO Date of Mark -out 3 Alin Date of Burial v /2` 1) Name of Funeral Home Authorized by J 6),(04:04114, 4 rs rvl c Co m bs Sales Tax Garage Sales Copies/Bid Specs. LDC /Code of Ordinances Election Qualifying Fees Cemetery Fees CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT White Dept. of Origin Yellow Finance Pink Applicant 4289 )(Cash ame h d 461,1 Cash Check ate l Check Amount Paid Amount Paid Time o. 01001 208001 01501 322900 01501 341920 01501 341910 01501 341930 Cemetery Lots l VW ltd 01010343800 Lot/Niche 20 Block 4 Unit 4 Total Paid 1000. Initials Iylials CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT Sales Tax Garage Sales Copies/Bid Specs. LDC /Code of Ordinances Election Qualifying Fees Cemetery Lots Lot/Niche Block 01501 343805 Cemetery Fees cfr Unit 4 Total Paid White Dept. of Origin Yellow Finance Pink Applicant 4739 /7 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. iLecto ra_ f'Yl e C',o m bS o v ken /o c Corn bs Name(s) c.1 Bri sit I Street Se- bas fl 3zg58 Address 0 6 (05 Area Code Phone Number MY Of AST HOME OF PELICAN ISLAND Name Residence Address of Intended Occupant if Other Than Purchaser Receipt is acknowledged in the sum of: (9. Q cute ck %p-0 Dollars C 0 0 O. 0 rd on this 2-3 day of March 20 1 i for the purchase of the following described Cemetery Lot(s) and /or Niche(s). Unit Block 4 Lot(s) 20 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 $20) Opening Closing 5C 0 Ivy 0 H Circle One Vase and Ring for Niches (cost) Temporary Marker Preparation Installation Signature of Purchaser 6 I: \WW- nATA\Ms- Cemeter \RFCEIPT.doc OFFICE USE ONLY Interment Disinterment TC\T 1 V 1 l1L Ci of Sebastian 1.56. WaLcuryva, The following documents were provided as Proof of Residency: �C. r l v 0'5 C, ceoseand FPL 51w-en/art- u_ U U_ O (n 4) Cn 0 IL a) 0 2 0 (0 O 5 c 0 0 a) (0 0 Z J N e O f- 0cd c') 0) O �Y X O M CO r e- r N 69646964 0 0 0 0 O N- 0 0 N e- 0 0 e- CO O Q rn e- e- 69 e- Q Efl6-69 0 0000 N (O CO N Ornt s e e- e- N 0 64 64 64 64 0000 N I CO O CO N LC) CO CO I- CO N- O) 64 69 64 64 CO 0 0 0 0 rn M -p O CO CO A C N CO L0 m 69 64 69 64 J CO 0 0 0 0 m oo00 0 0o 0 O_ 0000 L00 CO e 0 0000 N N N N N 0 0 0 r 0 c o 2 0 LL CO a Z O H u_ c IL 0) co 0 a E O 0 Lo ti m orn p 0 rn N j N y N N M LL 0 0 U- Q 0 O H O_ 0 Mrn =L01,- n E c` es 0 o 0 0 0 0 0 0 CO cO 0) CO M LO Ln O) CO CO 0 CO 0 N O N 0-00000 0 CO 0) Cs4 o 01 0 0) O N N m O O O 0 c C7 m U 0 2 J w 2 O O r M O w z 0 w w lY a 0 0 N 4 n N- LO 00 h N- C) 0 O 0) 0) 0) 0 0 0 0) 0) o) N N N d Lo Ln Lo Lo In In m 0 CO Ln CO CO N H Z W W 0 0_ 0 W Z a J J W 0 CL 0 0 N a in Z n 0 z O O FUNERAL HOME: ADDRESS: PHONE FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY (Check One) OPEN BURIAL LOT Lot OW Block L{ Unit 41 OPEN CREMAINS LOT Lot Block Unit OPEN COLUMBARIUM NICHE Niche Block Unit N S E W BURIAL DATE AND SERVICE TIME: FOR DECEASED: Kt n n e W-h /M C C rn b S Name oryOF HOME OF PELICAN ISLAND For information contact: Kip Kelso Cemetery Sexton Sebastian Municipal Cemetery (772) 589 -2545 City Clerk's Office City Hall, 1225 Main Street Sebastian, FL 32958 Office (772) 388 -8215 or 388 -8214 Fax: (772) 589 -5570 Ff0 *-en$€ 114(1(s NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Mus pro vide proper documentation of ownership) dor �a iid(e�'t e- C(,-,4 1. e- l� 6- VV G 0-1 LS 312.3 ame 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: 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: Cem tery/Se� This form to be provided to Clerk's Office by Sexton for permanent record upon completion. Jac/ D. A. (TYPE) Name of Deceased 3. Name of Medical Certifier Dr. Mohammad Idrees [Medical Examiner [Physician 4. Name of Funeral Home /Direct Disposal Establishment Hortense /Mills Memorial Funeral Home 5. Check a. fig Appropriate application. Box 6. Funeral Director/ Direct Disposer B. Method of Disposition: BURIAL ❑CREMATION DOTHER (Specify) Signature of Sexton or Person -in- Charge DH 326, 8/97 (Obsoletes all previous editions) (Stock Number 5740 000 -0326 -2) State of Florida, Department of Health, Vital Statistics APPLICATION FOR BURIAL TRANSIT PERMIT First Middle Last Kenneth McCombs 2. Place of Death City, Town or Location County Indian River Sebastian c Address Address 1454 Bellaire 4301 US Highway One The medical certification has been completed and signed. A completed certificate of death accompanies this b. was contacted on He /she verified that this death was from natural causes, that there was no accident nor other external cause of death, and that will complete and sign the medical certification of cause of death within 72 hours. medical certification of cause of death within 72 hours. ignature Death Name of (If neither, give street address) Hosp. or Sebastian River Medical Center Inst. Fla. Lic. No. /Reg. No. F040847 BURIAL TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No. 2123-07-11 A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has b -n 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. ❑No extension of time for filing th- ath certificate has bee requested Registrar or Date Date Certificate Subregistrar Signature o r� M /kilt( Issued: Due: was contacted on He /she verified that F.E. No.'. No. ate Signed., .er7 C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA Approval Number: Date Medical Examiner, Date Month Day Year of March 20,2011 Phone Number 772 589 -0069 Phone No. (Area Code) 772 569 -4626 Medical Examiner, will complete and sign the 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. CEMETERY OR CREMATORY Place of Disposition E161K7:4 &.P 4 ❑STORAGE Date of Disposition /4-4 This permit must be endorsed by the Sexton or person -in- charge (or by the Funeral Director /Direct Disposer when there is no Sexton) and returned within 10 days to the local County Health Department in the county where disposition occurred. Distribution: White: Cemetery or Crematory Yellow: Funeral Director or Direct Disposer Pink: Local Registrar Recycled Pape ect 25 11 03:25p Everlasting Stoneworks 17725899312 p.1 ifor City of Sebastian Sebastian Cemetery, Ph.0 1(772)539-2545 Fax 1(772) 228 9927 Note : This Is tor.loformatioaial purposes rewarding Monuments at Sebastian Cemetery. Note Please return to : Ory Mix _ Sebastian. Cemetery 1921 North Central Ave. Foundation routed 32958 - . by: everlasting/jarnie At1eotion Cemetery Sexton date: //3�z - stone.installed Size l-te _1-pq.Q•.7 standard grey granite flat grass marker by: everlasting/Jamie Names&Dates. His: I C _ date . �/�7,'t KQi)11f4�� eq)(eornJ s tier: . D.O.B. 11 I L I 1C1 D.O.B.. D.O.D. 31 ' e-, atD1 1 D.O.D. egat Description: Unit• Lot: �o. • Approved By: K . G . K. Checked By: K G . K . Date: BY: everlasting stone works °xample —1 "deep \ )Z l� 9ct 25 11 03:25p Everlasting Stoneworks 17725899312 p.2 c_d c 1 vgi 0 = = . ›.- '= • `1 ›' c----' CM - ,===, _c3, t:3,93 Po -r- .<--. .1;._ —.. Yij s.':' I . .._