HomeMy WebLinkAbout2-03-10DEED #359
Paid by General Receipt No. .....143... .... Dated. Jtirie..2.8,..1979.........
- -- Doris Peterson
100 , 00 1 + 1 cremains
. 'Maximum No. Burials aces Rte 1 Box +45
List Price $......•. p ............
Discount $. .............. Total area in square feet T:Ot 703 Shady Rest
Net Paid $. ?K0 .P0 .... Monument permitted .... flat........... Sebasler3__- (Roseland)
Cremains (Hiram F.)
R &R attached (Data above this line for City Record only) BLK 3 LOT 10 Unit #2
V
PETERSON, Doris
Rt.1 Box 45 DEED # 359
Lot 103 Shady Rest
Sebastian, F1.
.. ...........
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BLOCK 3 LOT 10 UNIT #2
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Cremains of Hiram F. in gravesite - 9118179 �'
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PETERSON, Doris
Rt.1 Box 45 DEED # 359
Lot 103 Shady Rest
Sebastian, F1.
.. ...........
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BLOCK 3 LOT 10 UNIT #2
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Cremains of Hiram F. in gravesite - 9118179 �'
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Index:
Name
ss 1
ss 2
City
Deed #
Unit #
Lot Number
Lot Number
Lot Number
Lot Number
Comment
Comment
C
Record:774
City of Sebastian, FL - Cemetery Lots
PETERSON First Name DORIS
RT . 1, BOX 45
SHADY REST, LOT 103
SEBASTIAN State FL Zip 32958-
359 Date 6 -28 -79 Amount $100
2- Block # 3
10 Interred PETERSON, HIRAM F. Dte Interred 09 -18 -79
Interred Dte Interred
Interred Dte Interred
Interred Dte Interred
Thursday, Jan 13, 2005 10:51 AM
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CITY OF SEBASTIAN
i CITY C RECEIPT OFFICE
3645
i
Name ..._. tiw. ❑ Cash
Date_ �.. " ° "" Nm2=
�7„'--
No.
Amount Paid
001001208001 Sales Tax
001501322900 Garage Sates
001501341920 Copies/Bid Specs,
001501341910 LDC /Code of Ordinances
001501341930 Election Qualifying Fees
601010 343800 Cemetery Lots
Lot/Niche Block _ . Unit
001501343805 Cemetery Fees , Od
On/¢
Total P &:eM In
als 4-
White - Dept. of Origin • Yellow - Finance • Pink • Applicant
BLOCK 3 LOT 10 Unit #2 DEED #359
Doris Peterson wife of whose cremains
were place�in the above lot on 9118179
Doris Peterson
Rt.1 Box 45
Lot 103 Shady Rest
Sebastian, F1..
PETERSON, Doris DEED # 359
Rt.1 Box 45
Lot 103 Shady Rest
Sebastian, Fl.
BLOCK 3 LOT 10 UNIT #2
Cremains of Hiram F. in gravesite - 9118179
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Name of Cemetery/Funeral Home FouNTATNHPAn mFmoRTAT. rr7NFRAT. i4otdy,j-
6224
RECEIPT OF CREMATED REMAINS AND RELEASE OF LIABILITY
The undersigned hereby certify that they have the legal right to take custody and make disposition of the cremated remains of tte deceased,
and hereby acknowledge receipt of the cremated remains of:
NAME OF DECEDENT: DORIS PETERSON
t.
The undersigned further assumes full responsibility for the lawful and proper disposition of said cremated remains.
The undersigned hereby agree to indemnify and hold harmless the above named cemetery/funeral home, its agents and employees from
any and all liability, including reasonable attorney fees, and against any loss it or any of them may sustain in connection with the receipt
of, shipment of, or disposition of said cremated remains.
Further, the above named cemetery/funeral home shall be held harmless from any defects or faults of any container not supplied by the
cemetery/funeral home. J
r•
Dated this / 2- day of d
Address
Street City State zip
Signature:
w, Authorized Re resentative SSN #/Photo ID Relationship to Drased
r
Signature:
A thorized ReprAntative SSN #/Photo ID Relationship to Deceased
Witness: 6�21 19 C--�
Representative of Cemetery/Funeral Home
cEN 5024 REV izwi White - Cemetery Copy Yellow - Customer Copy
r
ignity`
FOUNTAINHEAD MEMORIAL
CEMETERY ♦ FUNERAL HOME ♦ CREMATORY
7303 BABCOCK STREET, S.E.
PALM BAY, FL 32909
CERTIFICATE OF CREMATION
THE UNDERSIGNED CERTIFIES THAT THE REMAINS OF
DORIS PETERSON
WHO DIED ON: JUNE 19, 2006
WERE CREMATED ON: JUNE 259 20061
AND THAT ALL LEGAL REQUIREMENTS OF THE STATE OF
FLORIDA WERE OBSERVED IN PERFORMING SAID CREMATION,
AND THAT THE CREMATED REMAINS OF THE DECEDENT HAVE
BEEN PLACED IN A PROPERLY IDENTIFIED CONTAINER.
THE REMAINS WERE RECEIVED BY US FROM
FOUNTAINHEAD MEMORIAL FUNERAL HOME
BURIAL - TRANSIT PERMIT FH1442- 211 -06
CREMATION CERTIFICATE 06724
NAME OF CREMATOR
JUNE 25, 2006
DATE