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Certificate No. 2303
CITV OF SEBASTI i1
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Cathy Smiarowski
1306 Schumann Drive
Sebastian, FL 32958
In and for consideration of the sum of $1,200.00 is entitled to full interment
rights in the Sebastian Municipal Cemetery for the following niche:
Unit 3, Columbarium, Niche 23sn
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 5t" day of August, 2011.
CITY OF SEJBASTIAN, FLORIDA
rm
Al Minner
ty Manager
ATTEST:
Sally Maio, MMC
City Clerk
CITY OF SEBASTIAN
CITY CLERK'S OFFICE 4313
RECEIPT
Name &-h q Y I&Y- 0&A6 V-Cash
�i
Date O — 6' — / I ❑ Check A
No. Amount Paid
001001 208001 Sales Tax
001501322900 Garage Sales
001501341920 Copies/Bid Specs.
001501341910 LDCICode of Ordinances
001501341930 Election Qualifying Fees
601010 343800 Cemetery Lots �1 /.ZOO
Lot/Niche 3sn .Blocks, 1 Unit
001501 343805 Cemetery Fees
yo-St ri na 70.00
Total Paid 13,Z0.0
Initials
White - Dept. of Origin • Yellow - Finance • Pink - Applicant
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Name
Unit
Block
Lot Z l/Y
Date of Mark -out !�
Date of Burial_ Time
Name of Funeral Home
Authorized by
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
. SEW1V
nt�E a rttKN+ntN+o
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 -6,215 or 388 -8214
Fax: (772)'589 -5570
FUNERAL HOME:
ADDRESS:
PHONE #:
(Check One)
N BURIAL LOT Lot Block Unit
PEN CREMAINS LOT Lot -Block Unit
jk:� OPEN COLUMBARIUM NICHE Niche _V11 Block�v,� , Unit
W
BURIAL DATE AND SERVICE TIME: dap
FOR DECEASED: !
Name
IJAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE:
(Must provide proper documentation of ownership)
C""" 7i� � a� z•J!
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:
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
8 s- <i
cernfleryfiext6h Date
This fonTi to be provided to Clerk's Office by Sexton for permanent record upon completion.
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