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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 Ila, 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:
dl
Minner Sally A. aio, MMC
ty Manager City Clerk
CITY OF SEBASTIAN
CITY CLERK'S OFFICE
RECEIPT
4336
Name Q2oi D Cash
Date
No. Amount Paid
001001 208001
Sales Tax
001501 322900
Garage Sales
001501341920
Copies /Bid Specs.
001501341910
LDC /Code of Ordinances
001501341930
Election Qualifying Fees
601010 343800
Cemetery Lots
Lot/Niche . Block , Unit_
001501 343805
Cemetery Fees
L //, /;�lT, GC
jA . .
Total Paid / ✓'D
Initials
White — Dept. of Origin • Yellow — Finance • Pink • Applicant
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
5EBA� -"
ItOW Q+ FEttck" 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; *.ck Unit
_SJPEN COLUMBARIUM NICHE Nich Block Unit
_ W
BURIAL DATE AND SERVICE TIME: T/
FOR DECEASED: �G��g�� �f�j,��sa �� 5t- Amy! j�Af,A
INOrTle �IQpQ�L,t�15
NAME 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
NAI%1E AND SIGNATURE OF LICENSED FUNERAL DIRECTOR.
Name '1V1,4 Signature Date .-
--------------------------------------------------- ---- -------------- - - - - -- - - - --
Cemetery Sexton Certification:
I certify that I have checked the ownership infonrlatlon by viewing the owner's deed and confirming
with Clerk's office and th t all fees have been paid
,.-IA t2 4&.iF5
Ce etery exton Date
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.
w
b TAT EM E N T
DATE
TERMS
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IN ACCOUNT WITH
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