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Home My WebLink About4-06-07Name_ �ljst ilil/¢ J✓ �fti�� C?,__ 1�L� ?}i �- Unit Block Lot Date of Mark -out `l 13 ' Date of Burial � 5�� ' Time ZO O G Name of Funeral Home Authorized Certificate No. 2385 CUTY OF S-SEE/BASTI Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Kevin & Lucy Lovely Paul & Samantha Gautier 740 Barker Street Sebastian, FL 32958 In and for consideration of the sum of $5,000.00 is entitled to full interment rights in the Sebastian Municipal Cemetery for the following lots: Unit 4, Block 6, Lots 4, 5, 6, 7, & 8 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 21St day of June, 2013. CITY OF SEBASTIAN, FLORIDA AI Minner City Manager ATTEST: A Sally . Maio, MMC qty Clerk SAMANTHA ANN GAUTIER Mrs. Samantha Ann "Sammi" Gautier, 24, died June 20, 2013 at her residence in Sebastian. She was born March 7, 1989 in Norwood, Massachusetts and lived in Sebastian coming from Walpole, Massachusetts in 1990. She graduated from Sebastian River High School Class of 2007 and was a graduate of Indian River State College with an Associates Degree. She was employed as an Aesthetician with Mark's at the Pointe in Vero Beach. She was a member of Calvary Chapel of Melbourne, Sebastian Campus, Sebastian, FL. She was a member of First Descents, Denver, Colorado and Team Bombshell in Ormond Beach, FL. Survivors include her husband Paul Gautier, Jr. of Sebastian, children Tyler R. and Mason G. Gautier of Sebastian, parents Kevin and Lucy Lovely of Sebastian, sister Melissa Lovely and her boyfriend, Jeff Marinko of Vero Beach. CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT Name U- Date No. 001001 208001 Sales Tax 001501 322900 Garage Sales 4401 ❑ Cash // Y( Check # (D (`f Amount Paid 001501 341920 Copies /Bid Specs. _ 001501 341910 LDCICode of Ordinances _ 001501 341930 Election Qualifying Fees 601010 343800 Cemetery Lots _ `f Lot/Niche', Block (P Unit 001501 343805 Cemetery Fees _ of�l5 y.c) v 0j/, _ Total Paid 0 Uv Initials White - Dept. of Origin . Yellow - Finance • Pink • Applicant FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY HOME OF PEZAN 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: STRUNK FUNERAL HOME & CREMATORY 1623 No. Central eve. ADDRESS: SEBASTUIN, F1.3M tf► �eM PHONE #: (Check Ones >C OPEN BURIAL LOT Lot Block Unit 4 OPEN CREMAINS LOT Lot Block Unit OPEN COLUMBARIUM NICHE Niche Block Unit CIL N S E W BURIAL DATE AND SERVICE TIME: �S .2 J -- FOR DECEASED: ��r i l'l �il. ft � n Name NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of owne. hip), 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. NA E AND SIGNATURE OF LICENSED FUN DIR =CTOR: 1 MAb l'h q �A, t-1IC0[V LO 21)13 Name ignature T 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 that all fees have been paid: Ceme ry exton Date This form to be provided to Clerk's Office by Sexton for permanent record upon completion. F1ARL- ,- "-- ,- ,,- - --1-1— �+� State of Florida, Department of Health, Bureau of Vital Statistics HEART BURIAL TRANSIT PERMIT DATE PRINTED: June 21, 2013 TRACKING NUMBER: 2013090168 1. DECEDENT INFORMATION Name of Deceased Date of Death SAMANTHA ANN GAUTIER June 20, 2013 Place of Death - County City, Town or Location Name of facility, or street address if not a facility INDIAN RIVER SEBASTIAN 698 FISHER DRIVE 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: 2013- FO41870 -5099 Date Issued: June 20, 2013 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: �� 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, 10/12 64V- 1.011, Florida Administrative Code Total Paid W -00 Initials White - Dept. of Origin • Yellow - Finance • Pink . Applicant CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT /, `� 8 `+ v U ced( f ce,;,c( Name k-e y I ri L y y P l ❑ Cash `" e 3 Date r ❑ Check # No. Amount Paid 001001 208001 Sales Tax 001501 322900 Garage Sales 001501341920 Copies /Bid Specs. 001501 341910 LDC /Code of Ordinances 001501 341930 Election Qualifying Fees rj° � � roo 0 ' (1 00-00 601010 343800 Cemetery Lots .��' LbfflicTi� 7' Block Unit 001501 343805 Cemetery Fees Total Paid W -00 Initials White - Dept. of Origin • Yellow - Finance • Pink . Applicant 07 [)F SfOASTI - HOME Of PELICAN ISLAND 1! 1 IN •' �'� li • 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. K ► v 4 Name(s) uu '? 1 c 1 C \ A,ddre s (17 -Q 3 G 0 05q Area Code & Phone Number IA O V' Name & Residence Address of Intended Occupant if Other Than Purchaser Receipt is acknowledged in the sum of: on this. day of Cemetery Lot(s) and /or Niche(s). Unit , Block , Lot(s) Dollars ($ ) 20 for the purchase of the following described Niche(s) for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. Additional Fees paid at time of purchase: Corner Markers (set of 4 = $20) Vase and Ring for Niches (cost) Temporary Marker Preparation & Installation Signature of Purchaser Opening & Closing Interment /W O H Circle One Disinterme TlIT A t 1 V hL City of Sebastian The following documents were provided as Proof of Residency: !: \WW- DATA \Ms - Cemetery\RECEIPT.doc.. j and CULT n HOME OF PELICAN ISLAND Burial rights in the Sebastian Municipal Cemetery lots /niches purchased by me (Please print name and address of purchaser) `l (Lot/niche, block, unit description) are intended for interment of the following individuals: Please print name(s): Interment lots /niches are not to be transferred without written approval of the City of Sebastian. Interment lots /niches in the Sebastian Municipal Cemetery are allowed to be passed on to heirs but the City requires a certified copy of relevant probate or other court documents. I have read and understand the terms of this agreement. Signature Date Subscribed and sworn to before me this day of by who is personally known to me, or has produced as identification. Notary Public, State of Florida Names of Interred form Point & Pay - Create Order Thank you for your payment! This service has been provided by City of Sebastian, FL and Point & Pay. We value your business. Please keep this receipt for future reference. You have made a payment to City of Sebastian, FL . The City of Sebastian thanks you for your payment. For questions about your account, please call 772 - 589 -5330 Name: KEVIN LOVELY Address: 740 Barker St, Sebastian FL, US, 32958 Contact: 7724735808 Comments: Page 1 of 1