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Date of Burial Time a a C
Name of Funeral Home
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FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
IN
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: Strunk Funeral Home and Crematory
ADDRESS: 1623 North Central Avenue, Sebastian, Florida, 32958
PHONE* 772- 589 -1000
(Check One}
X OPEN BURIAL LOT
OPEN CREMAINS LOT
OPEN COLUMBARIUM NICHE
BURIAL DATE AND SERVICE TIME
Lot 36 Block 6 Unit 4
Lot Block Unit
Niche Block Unit
N S E W
Thursday, May 1, 2014 - 1;00 PM CHAPEL
FOR DECEASED: .lean Cebelius Schultz
Name
NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATVE:
(Must provide proper documentation of owner
Allen E. Schultz 4/28/2014
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 DIRECTOR:
Tim Marvin
Timothy W. Marvin ? 4/28/2014
Name Si nature_(
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 that all fees have been paid:
Cemetery Sexton Date
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.
State of Florida, Department of Health, Bureau of Vital Statistics
BURIAL TRANSIT PERMIT
�9
�..� ALTH DATE PRINTED: April 28, 2014 TRACKING NUMBER: 2014062512
1. DECEDENT INFORMATION
Name of Deceased Date of Death
JEAN CEBELIUS SCHULTZ April 27, 2014
Place of Death - County City, Town or Location Name of facility, or street address if not a facility
BREVARD MICCO 9852 RIVERVIEW DRIVE
Name and Address of Funeral HomelDirect Disposal' Establishment Fla. Lie. No.lReg. No. Phone Number
STRUNK FUNERAL HOME- SEBASTIAN F041870 F041870 (772) 589 -1000
1623 N CENTRAL AVE
SEBASTIAN, FLORIDA, 32958
Funeral Director /Direct Disposer Fla. Lie. 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: 2014- F041870 -5067
Date Issued: April 28, 2014
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 —M 'j L(f Ci I ., n `+
Method of Disposition: BURIAL Date of Disposition: I
EDRS maintains all statutorily required information regarding the death record and related
burial transit permit, therefore, returning the permit to the county health department is no
longer required.
If the Place of Final Disposition wishes to retain the copy of the permit for their file they may do so.
DH 326E, 10112
64V- 1.011, Florida Administrative Code
Certificate No. 2370
(CITY OF SSEB STI 1
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Allen E. Schultz &
Paula Schultz Bright &
Diane Schultz Helms
9574 Parker Drive
Micco, FL 32976
In and for consideration of the sum of $8,000.00 is entitled to full interment
rights in the Sebastian Municipal Cemetery for the following lots:
Unit 4, Block 6, Lots 35, 36, 37 & 38
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 23rd day of April, 2013.
CITY OF SEBASTIAN, FLORIDA
'k Al Minner
City Manager
ATTEST:
Sally . Maio, MMC
City Clerk
Total Paid ®�V• v
Initials
White — Dept. of Origin • Yellow — Finance • Pink - Applicant
CITY OF SEBASTIAN
CITY CLERK'S OFFICE
RECEIPT
4371
Name
❑ Cash
Date Z 3
j
_ a 3
❑ Check #
efp4tif eilr
No.
Amount Paid
001001208001
Sales Tax
001501322900
Garage Sales
001501341920
CopiesBid Specs.
001501341910
LDCICode of Ordinances
001501 341930
Election Qualifying Fees
601010 343800
Cemetery Lots
3 E Block
Unit
LottNichjl ,
36
001501 343805
CemetJe sr
Total Paid ®�V• v
Initials
White — Dept. of Origin • Yellow — Finance • Pink - Applicant