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Authorized by
Certificate No. 2366
CITY OF SEBASTIAN
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
James E. &/or Lisa K. Rogers
165 Columbia Avenue
Sebastian, FL 32958
In and for consideration of the sum of $1,500.00 is entitled to full interment
rights in the Sebastian Municipal Cemetery for the following lots:
Unit 4, Block 8, Lots 11a, 12a & 13a
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 1st day of April, 2013.
CITY OF SEBASTIAN, FLORIDA ATTEST:
d
` Minner Sally A,,Maio, MMC
ity Manager City Clerk
CITY OF SEBASTIAN
CITY CLERK'S OFFICE
RECEIPT
NameV ,[.Ur+ G�� �Ll Ski x &P o Cash
Date 7/Z51�3eck#
No.
001001 208001 Sales Tax
001501322900 Garage Sales
001501341920 Copies/Bid Specs.
001501 341910 LDC/Code of Ordinances
001501341930 Election Qualifying Fees
601010 343800 Cemetery Lots
LoMiche , Block , Unit_
001501 343805 Cemetery Fees
zNWO
4336
Amount Paid
Total Paid /�
Initials
White — Dept. of Origin • Yellow — Finance • Pink . Applicant
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
IIDM( Qi PELICAN ISLAND
For information contact:
Kip Kelso - Cemetery Sexton
Sebastian Municipal Cemetery
(772) 589-2545
City Clerk's Office
City Hall. 1225 Main Street
Sebastian, FL 32958
Office (772) 388-8215 or 388-8214
Fax: (772) 589-5570
FUNERAL HOME:
ADDRESS:
PHONE #:
(Check One)
OPEN BURIAL LOT Lot Block Unit
PEN CREMAINS LOT Lot L Unit
_— - PEN COLUMBARIUM NICHE Nich Block Unit
VV
BURIAL DATE AND SERVICE TIME:
FOR DECEASED: r",C-W, J<Q 5}• •
[Name �2pfo—,t2rj
14AME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE:
(Must provide proper documentation of ownership)
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 SIGNATURE OF LICENSED FUNERAL DIREC70R.
Name -Signature
Date
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Cemetery Sexton Certification:
I certify that I have checked the ownership inforn-iat�on by viewing the owner's deed and confirming
with Clerk's office .and th t all fees have been paid
�" 2
Cee t e r 77 exton Date
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.
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City of Sebastian
Sebastian Cemetery
Ph. # 1(772) 589 - 2545
Fax # 1(772) 228 9927
Note This Is for Informational purposes reguarding Monuments at Sebastian Cemetery .
Note Single, Double , & Triple flat grass marker's require a Dry Mix (sakcrete )
Note Single, Double, & Triple up - right marker's w / or without a base & over 2 Ft. long
require a poured concrete foundation I
Dry Mix
Note Remit to Sebastian Cemetery
1921 North Central Ave. Foundation poured
32958 by ; Everlasting / jamie
Attention Cemetery Sexton date : 5/20/13
stone installed
by : Everlasting/ jamie
Size 1 - 0 x 2 - 0 x 0 - 4 standard grey granite flat grass marker date : 5/20/13
Names & Dates :R
His : Her: Joanne'B- TNI7
D.O.B. D.O.B. 1951
D.O.D. D.O.D. 1999
Legal Description
Unit : 4
Blk.: 8
Lot : 11 -A
Approved By: K. G. K.
Checked By: K. G. K.
Date 5/20/13
By: everlasting monument co.
Example: At all times send a picture of monument in question with this form ( fax a copy !) !
2 " granite headstone
4"deep J--\ \ \ \ 12"
CA
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