HomeMy WebLinkAbout1-30-13. — . , ___ _._ _ _ _
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?aid by General Receipts NoS...l�? f 148� 150Dated..12�7�9�70_ `.... .. Ned L UI
• ... ... .. . .... . illiams
:ist Price �, *600.00�'... ' 2735 52nd Ave.�
•• •• Maximum No, Burial spaces 3 0 1073
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)UNE EILEEN WILLIAMS
Born: October 8, 1921
Passed Away: February 6, 2012
Mrs. ]une Eileen Williams, 90, died February 6, 2012 in Stockbridge, Georgia.
She was born in Hicksville; Ohio lived in Sebastian, Florida prior to relocating to
Stockbridge, Georgia.
Survivors include her daughters, Patricia Davis of Stockbridge, GA, Jacqueline
Young of Vero Beach, Diane Hanisch of Walsenburg, CO; 6 grandchildren, 11
great-grandchildren. She was preceded in death by her husband, Ned Lee
Williams.
Georgia Department of Community Health
Vital Records Service
PERMIT FOR THE DISPOSITION OF HUMAN REMAINS PERMIT NUMBER 5,73�
Name of Deceased Date of Death Fetal Death?
�Un�
of Death (Hospital or
� �li ms
OR Interment (Cemetery)
a— 6 �� �� 3. Yes � No_❑
X
or Location of Death
of Death OR interment
Residence , �
120 Cowan Trail, StockbridgeGA 30281 �TKY
a. s. s.
Name of Certifying Physician, Coroner, or Medical Examiner Certifiers Address (Not Used for DisintermenUReinterment)
(Not Used for DisintermenUReinterment) ,� � � 4.--,GY„_1 , — �� \ _ t°--1�
Dr. Sarmiento -r'+' � c�.sz_� 4_.�
7. s. c� ���. E �'�� ��1��C t-`7�"�...r l" ) r 1` <° .
Funerai*tidf�T�'NaM�'3hEffCdtliCSS Funeral Home Lic. No. .
Cannon Cle�aeland Funeral Directors
9 2580 Hwy 42 North, McDonough, GA 30253 �a 1550
Method of Disposition OR Date of Disposition OR
Reinterment
11. Cremation ❑ Donation ❑ Other ❑ Removal From State � DisintermenUReinterment ❑ 12.
Name andA ddress of DisposiUon OR Reinterment Site Location of DisposiUon OR Reinterment Site
Sebastian Cemetery �county, ciryorstate)
13. �4 Sebastian FL,
31-10-20.(a) The funeral director or person acting as such, or other person who first assumes custody of a dead body or
fetus shall obtain a disposition permit prior to cremation or removal from the state of the body or fetus. A disposition
permit may be required within the state by local authorities.
Local �tal Records Registrar—
,! J
Sexton (or Person In Charge) —
� '
(
�- ��',� • �/G�cl-S� � l.l �B/+�7F� �.lG/�
� � � 1
C�.ei�%��
Date Signed
16.
1 `.
FUNERAL DIRECTOR'S REQUEST TO CITY UF SEBASTIAN
FOR BURIAL OPENING !N SEBASTIAN MUNlCIPAL CEMETERY
una
HOME OF PEl1CAN KIAPD
For information contact:
Kip Kelso - Cemefery Sexfon
Sebastian Municipal Cemetery
(772) 589-2545
City Clerk's Offrce
City HaN, 9225 Main Sfreet
Sebasfian, FL 32958
Ofi�ice (772) 388-8295 or 388-8294
Fax: (772J 589-5570
FurvEwq� HonnE: STRUNK �UNERAL HOME � CREMA70RY
• e.
ADDRESS: SEBASTiAN FL 3295
PHONE #: 89���
- i�( h One) \��(�,� '� �I JCJ
OPEN BURIAL LOT Lot �_ Block �i� Unit I
OPEN CREMAINS LOT Lot Block Unit
OPEN COLUMBARIUM N1CHE Niche Block Unit
N S W y��
BURIAL DATE AND SERVICE TIME: �%�1�(--� ;�- / b��L (� I 1- �U 77 /�1
FOR DECEASED: _��U'1 � � I�C?i``� (�v � I( l Gia'Yl`�
Name
NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE:
Must provide prope documentation of o hip)
��v��s � � ' �,
� �� �--�.�1�,
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 SIG��URE OF LICENSED FUNE�L DIRECTOI�:
� �.QJ'� r� YLC.►'� � �'?�c-n � 2� 7�"�C�--
'� --�—_
Name gnature Date
Cemetery Sexton Certification:
I certify that I have checked the ownership inforrnation by viewing the owner's deed and confirming
with Clerk's o�ce and t at all fees have been paid:
� ,� o i� .
Cem tery ex on D te
This form to be provided to Clerk's Office by Sexton for permanent record upon cornpletion.