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Home My WebLink About2-15-02Name Unit Block /-j Lot A/ /42 / Date of Mark -out 4�J Date of Burial ✓ ? 1 ✓ ' ' Name of Funeral Home Authorized by Time D Fu t4ERAL DIRECTOR'S REQUEST TO CITY OF SE13ASTIAN FOR�IJRIAL OPENING IN SEBASTIAN MUNICIPAL CEM URY WW 04 11tICAN For information contact: Kip Kelso . Cemetery Sexton Sebastian Municipal Cemetery (772) 689-2546 City Clerk's Office City Hall, 1225 Main Street Sebastian, FL 32958 OtHce (772) 388-9215 or 288.8214 Fax: (772) 589-5570 FUNERAL HOME: ADDRESS: PHONE #: (Check One) ,Lot Block Unit JOPEN BURIAL LOT OPEN CREMAINS LOT Lot 2, Block L!. --Unit Unit PEN COLUM4ARIUM NICHE Niche Block W BURIAL DATE AND SERVICE TIME:1�rlffp FOR DECEASED.Z. Name NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership) A r la �/d 1 G titJ' . /� D L��4w - Date Name Signature I certify f that I have determined the ownership of the above described site that all site fees and administrative fees hese been paid and authorize opening of same NAME AND SIGNATURE OF LICENSED FUNERAL DIRECTOR. i nature Gate tvame r ---..r..... �• •..... •..r...r•.r...•.. •..w... ..........•.................... 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 'A/co 4::�21- 2 Z4 - Cemdlery Rexton Date This fora to be p rovided to Clerk's Office by Sexton for permanent record upon completion. A Paid by General Receipt No. 125 List Price $. gQQ, 00 Discount Net Paid $ $200.00 DEED #347 Dated ... January. 5., • 1979 Robt & Colleen Holland Soy Palm Ave, Seb Highlan Lots 1 & 2 B1k 15 Uni Maximum No. Burial spaces ....2 Total area in square feet Monument permitted.. • •flat (Data above this line for City Record only) Holland, Robert & Colleen 509 Palm Avenue Sebastian, F1 32958 Block 15, Lots 1 & 2, Unit 2 Robert Holland interred in lot 2 in January 1979 Scott Holland (son) interred lot 1, 12/17/80 Di nit FOUNTAINHEAD MEMORIAL CEMETERY ♦ FUNERAL HOME + CREMATORY 7359 BABCOCK STREET, S.E. PALM BAY, FL 32909 CERTIFICATE OF CREMATION THE UNDERSIGNED CERTIFIES THAT THE REMAINS OF COLLEEN THERESA HOLLAND WHO DIED ON: WERE CREMATED ON: MARCH 9, 2016 MARCH 24, 2016 AND THAT ALL LEGAL REQUIREMENTS OF THE STATE OF FLORIDA WERE OBSERVED IN PERFORMING SAID CREMATION, AND THAT THE CREMATED REMAINS OF THE DECEDENT WERE PLACED IN A PROPERLY IDENTIFIED CONTAINER. THE REMAINS WERE RECEIVED BY US FROM FOUNTAINHEAD FUNERAL HOME BURIAL -TRANSIT PERMIT - 2016-FO56369-5062 CREMATION CERTIFICATE 13908 SIGNATURE OF CREMATOR MARCH 24. 2016 DATE 317krt iJlr rks.., l t DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES VITAL STATISTICS APPLICATION FOR BURIAL -TRA' SIT PERMIT NAME OF DECEASED (Type or print) First Robert Middle Lost Holland PLACE OF DEATH COUNTY Indian Attending Physician Medical Examiners Funeral Home River Keith CITY, TOWN, OR LOCATION Roseland. Florida /'1024 /Jr�%o2. DATE Month Doy Year OF DEATH December 28, 1978 lNAME OF (If not in hospital, give street address) I a�TUTIOOrbebastian River Medical Cente (Name of Medical Certifier Kirby M.D. 3403 Ocean Drive (Address) Vero Beach, Florida 32960 Check One (Name) Colonial Funeral Home S. Indian River (Address) Dr. Sebastian, Florida 32958 r A Et A completed certificate of death accompanies this application. B ❑ Dr was contacted on , 19 He has assured me that this death was from natural causes and that he will complete and sign the medical certification of cause of death. C ❑ The attending physician was unavailable or this death comes within the Medical Examiners jurisdiction. The body was released to me by on. , 19 Funeral Director (Signature) 1579 (Fla. Lic. No.) Dticembair 2R, 1978 (Date Signed) BURIAL TRANSIT PERMIT Permit No 7S ?"14-.CP Permission is hereby granted to dispose of this body by burial, transportation out of state, storage or cremation. For cremation a waiting period of 48 hours after death must be observed and the Medical Examiner's approval must also be obtained. ❑ A five day extension of time for filing the death certificate has been requested and granted. Signature of Registrar L k -4. 4 Method of Disposition BURIAL ❑ CREMATION ❑ STORAGE ❑ OTHER (Specify) Signature of Sexton or Person in Charge This permit must be endorsed by the sexton or person in charge or by the funeral director when there is no sexton) and returned within 10 days to the local county health department. Daue p Issued p a 1 7� COY OR CREMATORY Date of Disposition January 1, 1979 Place of Disposition Sebastian Cemetery MRS Form 326 (1/77) CITY OF SEBASTIAN FINANCE DEPARTMENT RECEIPT ; (loop Name E rl G Holland [Cash Date Z4-1— Ile ❑ Check # ❑ Credit Amount Paid 001001 208001 Sales Tax 001001 220000 Security Deposit - 001501 362100 Taxable Rent - 001501 362150 Non -Taxable Rent - 450010 369900 Airport Badge 001501 329500 Alarm Permits 001001 218010 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 DOlSo I -N VOS v/G DO aZ 1415 LO/ -� 5M Total Paid 50 00 Initials White - Dept. of Origin • Yellow - Finance • Pink - Applicant Edited by Foxit Reader Copyright(C) by Foxit Software Company,2005-2006 For Evaluation Only. Cl o City of Sebastian �ebaslian Cememrr Pit. # 11772) 589 - 2545 Fbv k 1(7721 228 -9927 .Note This Is for Informational purposes reguarding Monuments at Sehastlan Cemeten . Nole : This is for Single Markers under 2 ft. S over 2 ft.( over 2 ft. is a poured foundation ) Please return to Attention Size Name & Date HIS D.O.B. D.O.D. City of Sebastian Sebastian ('enufers' 1921 North Central Ave. 32958 Ceutelery Sexton HER: D.O.B. D.O.D. Legal Desciipition yL Unit Elk . : Lot Square Ft. Approved By Checked By Dry Mix s Foun aeon pouredBy �y e date 12) I ► Y .lour installed. date 401 laf)o/ DATE 14 - By - By Example NOTE ANY MARKER OVER 2 FT. LONG REQUIRES A POURED CONCRETE FOUNDATION THIS INCLUDES A BASE. ANY MARKER SMALLER THAN 2 FT. LONG REQUIRES A DRY MIX THIS INCLUDES A FLAT GRASS MARKER. tA J O CL W a 0 a a m a O Q LL 0 a P o W � U X � O O w " O J O m o O w O ¢ a w U Q Q N U 3 C7 2 w z 0 N U Z r Y o m U ^ s m U = v Q N a U LL p U - g w ¢ O r w ¢ o O U n 0 0 0