HomeMy WebLinkAbout3-COL-01Certificate No. 2383
CITY OF SE B.STIN
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Helga Dubuque
581 Concha Drive
Sebastian, FL 32958
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 niches:
Unit 3, Columbarium, Niche idsa & 2dsa
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 19th day of June, 2013.
CITY OF SEBASTIAN, FLORIDA ATTEST:
AWlinner SallyP . Maio, MMC
ty Manager City Clerk
Total Paid 460o VO
Initials
White - Dept. of Origin • Yellow - Finance • Pink . Applicant
CITY OF SEBASTIAN
CITY CLERK'S OFFICE
RECEIPT
/, 9
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Name
❑ Cash
Date '"
XCheck# lyZ
No.
Amount Paid
001001 208001
Sales Tax
001501 322900
Garage Sales
001501 341920
Copies /Bid Specs.
001501341910
LDC /Code of Ordinances
001501 341930
Election Qualifying Fees
�0
601010 343800
Cemetery L its
C�Sc.
(�0•
LoUNiche Z a- , Block �--'0 I
Unit
001501 343805
Cemetery Fees
Total Paid 460o VO
Initials
White - Dept. of Origin • Yellow - Finance • Pink . Applicant
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bTATEMENT
DATE /
TERMS
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DATE OF BIRTH: � 1 G � °i �
(Month) (Day) (Yew)
DATE OF DEATH:
(Month) (Day) (Year)
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SIGNATURE � A G 01 _y c.
DATE:
FOR OFFICE USE ONLY
Unit 3
Double / South / A
COLUMBERIUM:
NICH �S
NUMBER-.
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NAME
(First)
DATE OF BIRTH:
DATE OF DEATH:
SIGNATURE::
PLEASE PRINT
(Middle)
(Month) (Day)
(Month)
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(Last)
{ Ycar }
(Day) ( Year)
PRINT
SIGNATURE:;
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DATE: 77 --
FOR OFFICE USE ONLY
Unit 3
Double / South / A
COLUMBERWINI: Z5A
NIGH �5
NUMBER: