HomeMy WebLinkAbout2-03-08W
N
Alp-
jvlt
rrafi�
Cny Of
SEsAST_"
HOW Of PWCM K"
Certificate # 1882
COPY
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian,
it is hereby certified that:
James Sexton
(name)
(name)
(name)
297 Manly Avenue, Sebastian, FL 32958
(address)
(address)
(address)
in and for consideration of the sum of $700.00 , has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plot:
Unit 2 , Block 3 " Logs) — 8
of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and regulations
prescribed therefore by the City of Sebastian.
CONVEYED THIS 20th day of March 9 2003 .
CITY OF SEBASTIAN, FLORIDA ATTEST:
&0. M
Terrence R. ore y A 0, C M C
City Manager City ClJo
0
CITY OF SEBASTIAN
CITY CLERK'S OFFICE
RECEIPT
1575
Name Sexton
❑ Cash
Date 3 -19 -03
2992
DE Check tY
AnanntPWd
001001 208001 Sales Tax
001501322900 Garage Sales
001501341920 Copies/Bid Specs.
001501 341910 LDC/Code of Ordinances
001501362100 Community Center Rent
001501362100 Yacht Club Rent
001501362150 Non Taxable Rent
001501 343800 Cemetery Lots
!
601010343800 Cemetery Lots
700.00
Lot/Niche 8 Block 3
Unit 2
001501369400 Interment Fee
75.00
001501 369400 Weekend Service
680800 220681 Yacht Club Security Deposit
680800 220682 Community Center Security Deposit
680800 220683 Riverview Park Security Deposit
775.00
Total Paid
Gin Male
Whi",otal n • Yellow — Finance • Pink • Applicant
The Sebastian. Cemetery
City ®f Sebastian, Florida
Receipt is acknowledged in the sum of:
Seven hundred and no/ 100------------------ ---------- Dollars ($ 700.00 )
From: James Sexton
297 Manly Avenue, Sebastian, FL 32958
P 1 L6rwC. (772) 581 -3499
on this 19th day of March 20 03 for the purchase of the following
described Cemetery Lot(s)/Niche(s) upon the terms and conditions as stated herein:
Description of Property:
Cemetery Lot(s)/Niche(s)
Purchase Price:
Block 3 Unit 2
Seven hundred and no /100------ - - - - -- Dollars ($ 700.00 )
Terms and Condition of Sale:
This contract shall be binding upon both parties, the seller and the purchaser, when approved
by the owner of the property above described.
T, or we, agree to purchase the above described property on the terms and conditions stated in
the foregoing instrument:
Purchaser signature
The City of Sebastian agrees to sell the above mentioned property to the above named
purchaser(s) on the terms and conditions stated in the above instrument.
FLORIDA DEPARTMENT OF
HEALT
4. (TYPE)
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
t. Name of
First Middle
Last
Date
Month Day Year
Deceased
Paula Diane
Grubbs
of
March 17, 2003
Death
2. Place of Death
City, Town or Location
Name of (If neither, give street address)
County Polk
10 ml. North of Haines
City
Hosp. or Dean Still Road
Inst.
3. Name of Medical
Alexander Melamud, MD
Address
2145 Marshall Edwards Drive
Phone Number
Certifier
Bartow, FL 33830
863 -687 -1100
Medical Examiner MPh ician
ys
3. Name of Funeral Home /Direct Disposal
Address
Fla. Lic. No. /Reg. No.
Phone No. (Area Code)
Establishment
1010 E. Palmetto Ave.
Brownlie- Maxwell
Melbourne,
FL 32901
0000049
321/723 -2345
Check a.
Appropriate
Box
G G C. o
The medical certification has been completed and signed. A completed certificate of death accompanies this
application.
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.
was contacted on
He /she verified that
Medical Examiner, will complete and sign the
mof# certifjotig.6 of taus f death within 72 hours.
3. Funeral Director/ Si F.E. No. /Reg. No. Date Signed
Direct Disposer 2045 March 19, 2003
3.
BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. an -Ir n4g
® A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has
been 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 the d certificate as been requested.
Registrar or Date Date Certificate
Subregistrar Signature Issued: 3/19/03 Due:
AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA
Approval Number: Date
Medical Examiner, , 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.
D. CEMETERY OR CREMATORY Sebastian Cemetery
Method of Disposition: Place of Disposition Sebastian, Florida
®BURIAL
CREMATION
Signature of Sexton 1
or Person -in- Charge J}
STORAGE
OTHER (Specify)
Date of Disposition 3 /g4 /a i
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
3H 326, 8/97 (Obsoleles all previous editions) Yellow: Funeral Director or Direct Disposer
Stock Number 5740 -000- 0326 -2) Pink: Local Registrar