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Home My WebLink About4-12-05CITY OF ��►�'�,';� _� , .� ..�_ _ � HOME OF PELICAN ISLAND Certificate No. 2356 C�� 0 "� .� `';��'�1�� Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Betty Stephens 103 Cherokee Court Barefoot Bay, FL 32976 In and for consideration of the sum of $4,000.00 is entitled to full interment rights in the Sebastian Municipal Cemetery for the following lot: Unit 4, Block 12, Lots 5& 6 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 31t" day of December, 2012. CITY OF S�BASTIAN, FLORIDA ATTEST: � ' �I Minner City Manager f � � ��/9 ��' � ' i l Sall . Maio, MMC City Clerk i� Name Unit Block �� ot T • Date of Mark-out � /�l /� 3 • Date of Burial ! / �/i � • Time 2 � . �L � �'^ ,/ Name of Funeral Home ��l� �s ht /C ' it • _ „ _ Authorized by 7 � 3 y d � r � � S m � � 0 � � O m � • s m ec i T � m • � � � 6 s � � lJ d M d � ��* Cl � C � C/ 0 0 A O � o °o °o °o °o °o z v o ei ° o 0 0 0 °o � o � A � � A N O OWO CO t0 f0 (ND O � O O O O O � t � � � � o o d � a Z� o �� y � � � � � � � � � � � � � a � � (D 0 � � � y � � -Z' O � � n � � m � W y N � _ N c � i � i � i i I I 0 z d m � � � � � d � N � ? � n s 0 c .�. � �: � n A �� n � mm0 � � � � � � O y T „� T c n y mz � � � � � ELMER M. STEPHENS Elmer M Stephens, 76, died December 29, 2012 at Sebastian River M�dical Center in Sebastian. Mr. Stephens was born February 19, 1936 in Mt. Hope, New Jersey and lived in Barefoot Bay since 1993 coming from Elmwood Park, NJ. He served aboard the U.S.S. Radford and the U.S.S. Bayfield during the Korean War earning the National Defense Service Medal and the China Service Medal. He was of the Presbyterian faith, a life member of the NRA and a life member of VFW Post 281, Fair Lawn, NJ, where he was a very active member of the Ritual Team. He is survived by his wife of 54 years, Betty L. Stephens of Barefoot Bay. He was preceded in death by his sister Janet Stephens Atta. �� 1 EL°w°�nII'"xra'�'r°F'. ,�' State of Florida, Department of Health, Bureau of Vital Statistics ��T BURIAL TRANSIT PERMIT DATE PRINTED: December 31, 2012 TRACKING NUMBER: 2012181800 1. DECEDENT INFORMATION Name of Deceased Date of Death ELMER M STEPHENS December 29, 2012 Place of Death - County City, Town or Location Name of facility, or street address if not a facility INDIAN RIVER SEBASTIAN SEBASTIAN RIVER MEDICAL CENTER Name and Address of Funeral Home/Direct Disposal Establishment Fla. Lic. No./Reg. No. Phone Number STRUNK FUNERAL HOME- SEBASTIAN F041870 F041870 (772) 589-1000 1623 N CENTRAL AVE SEBASTIAN, FLORIDA, 32958 Funeral Director/Direct Disposer Fla. Lic. No./Reg. No. TIMOTHY W. MARVIN F022789 2. BURIAL - TRANSIT PERMIT The Florida Department of Health, Bureau of Vital Statistics hereby grants permission to dispose of this body in accordance with Chapter 382, Florida Statutes. Permit Number: 2o12-FO4187o-5108 . aG / //�• Date Issued: December 31, 2012 Lt• �'' J Meade Grigg, State Registrar 3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL-AT-SEA, or HOSPITAL DISPOSITION Authorization given by Medical Examiner District Approval Number: 4. CEMETERY OR CREMATORY Place of Disposition: SEBASTIAN CEMETERY Method of Disposition: BURIAL Date of Disposition: /�. _ Signat re of xt or person-i charge (or by the funeral director/direct disposer when there is no sexton) DH 326E, 1/11 64V-1.011, Florida Administrative Code FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY urva HOME OF PFUUN KIAHD For information contact: Kip Kelso - Cemefery Sexton Sebastian Municipal Cemefery (772) 589-2545 City Clerk's O�ce City Hall, 1225 Main Street Sebasfian, FL 32958 Office (772} 388-8215 or 388-8214 Fax: (772) 589-5570 FUNERAL HOME: �r�� ERA� HOME & CR��?A;f��?Y ��3-rfo:-%rttPa ve. ADDRESS: SEBASTIAN, FL 32958 PHONE #: jT3 -10pQ ( eck One) t� OPEN BURIAL LOT OPEN CREMAINS LOT OPEN COLUMBARIUM NICH BURIAL DATE AND SERVICE TIME FOR DECEASED: �I`Y) �l� Name Lot � Block � Unit T Lot Block Unit E Niche Block Unit InIE�►� ` /�--�i� - �� t-'1 M� ��r�� NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership} --�� . � � � � �- � � Name Sig a re ate 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 FU L DIR CTOR: /�r�tG7 '�Y� �v�r� fi � �' � - � .��!/ r � Name ignature 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 hat II fees have been paid: � ��/ / � �//� Cem ery S to Date � This form to be provided to Clerk's Office by Sexton for permanent record upon cornpletion. �� : �; ��, ,�� . $�� .� ��'��- � ��: OiQ3�1E �3F PEiICA[�I 45I1�h1D � a3�- � City of Sebasiian il�llur►icipal Cerrietery Purchase Receipt To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate regulations, proof of City residency of purchaser or person for whom lot is intended for interment must be provided at time of purchase. Name(s) Address ❑� Area Code & Phone N Name & Residence Address of Intended Occupan�if Other Than Purchaser OFFICE USE ONLY Receipt is acknowledged in the sum of: � � Dollars ($ f �QD o � � � on this. � � S� day of ,CCM�-�.�, 20 �� for the purchase of the following described Cemetery Lot(s) and/or Niche(s). r : Unit �_, Block �, Lot(s) C Niche(s) for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribeci therefore by the City of Sebastian. Additional Fees paid at time of purchase: Corner Markers (set of 4 = $2 Vase and Ring for Niches (cost) Temporary Marker Preparation & )nstallati �� ignat re of urchaser Opening & Closing Interment /W O H Circle One Disinterment 1 V I ln1nL � � � .. 1� Sebastian The following documents were provided as Proof of Residency: !:\VVW-DATA\Ms-Cemeterv\RF�FIpT.dor � ana Name No. 00100t208001 001501322900 001501 341920 001501 341910 001501 341930 601010 343800 001501 343805 CRY OF SEBASTIAN CITY CLERK�S oFF��E . 4 7 6 8 RECEIPT > ❑ Cash Check # Amount Paid Sales Tax Garage Sales Copies/Bid Specs. LDC/Code of Ordinances Elec6on �ualitying Fees Cemetery Lofs � LoUNiche . � � , Block1�, Unit� G'C Cemetery Fees �— � a� Total Paid ` �� Initi�ls White - Dept. of Ori in • Yellow - Finance • Pink - Applicant