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Home My WebLink About4-06-151 11 Name �� / S C' -5- t , ! �` '� 0 ?1 � Unit Block Lot Date of Mark -out 2 Date of Burial 3L J ' Time �/ . 3a Name of Funeral Home r_m1ht.7rrsx• by MADISON JANE SMITH Miss Madison Jane Smith, 6, died August 17, 2013 at Baptist Medical Center in Jacksonville. Madison was born October 15, 2006 in Melbourne, Florida and was a lifetime resident of Fellsmere, FL. She was a student at Pelican Island Elementary, Sebastian; and a member of the Horse'n Around Club in Fellsmere and the Indian River Riding Club. Survivors include parents, Timmy and Janie Smith of Fellsmere; sister, Taylor Smith of Fellsmere; fraternal grandparents, Tim and Brenda Smith of Ellijay, Georgia; and maternal grandparents, Jim and Betty Schaus of Ft. Walton Beach, FL. CRYOF SEAN HOME OF PELICAN-ISLAND Certificate No. 2388 C I Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Dawn Biehl 1570 Bevan Drive Sebastian, FL 32958 In and for consideration of the sum of $3,000.00 is entitled to full interment rights in the Sebastian Municipal Cemetery for the following lots: Unit 4, Block 6, Lots 14, 15 & 16 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 20th day of August, 2013. CITY OF SEBASTIAN, FLORIDA ATTEST: I Minner Sally .Maio, MMC City Manager City Clerk ( j Total Paid Initials White - Dept. of Origin • Yellow - Finance • Pink - Applicant CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT 4800 � bc.-w ��`` rl � �i Name U F ❑ Cash Date F-2,043 7 c Check #3q 15 NO No. Amount Paid 001001 208001 Sales Tax 001501 322900 Garage Sales 001501 341920 Copies /Bid Specs. 001501 341910 LDC /Code of Ordinances 001501341930 Election Qualifying Fees 601010 343800 Cemetery Lots 00 LoMiche 14 15 1 , Block 62 Unit I_ 001501 343805 Cemetery Fees ( j Total Paid Initials White - Dept. of Origin • Yellow - Finance • Pink - Applicant ,cm QF S A T HOME Of PELICAN ISLMD City o'. Sebastian 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. I Ct. w n - NamP(�l yc�_n Dr i e6a_jfi &ri FL 3Z t59 Address 473-:3 &5f Area Code & Phone Number l 4 i's (y1 i S D rn Sm Name & Residence Address of Intended Occupant if Other an Purchaser • s Receipt is acknowledged in the sum of: Dollars ($3000, 0Q) on this. day of 20 for the purchase of the following described Cemetery Lot(s) and /or Niche(s). Unit Z , Block Lot(s) I, (,5, d 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) Opening & Closing Vase and Ring for Niches (cost) Temporary Marker Preparation & Installation '. • - bf Purchaser Interment I: UMN- DATAWIs- Cemeterry \RECE1 PT. doc /W O H Circle One Disinterment TOTAL $CUO, Uv 9 ty of Sebastian The following documents were provided as Proof of Residency: and FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY Mi SE T_" HOME C* PELICAN 15LAW 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 STRUNK F& OMR -E' °CREMATORY FUNERAL HOME: 1623 No. Central Ave. SEBASTIAN, FIL 32958 ADDRESS: (772) 589 -1000 PHONE #: /(Check One) ff ,^, 1 OPEN BURIAL LOT Lot 15 Block W Unit `� OPEN CREMAINS LOT Lot Block Unit OPEN COLUMBARIUM NICHE Niche Block Unit N 5 E W BURIAL DATE AND SERVICE TIME: FOR DECEASED: M aCUSon Name NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership) f �&� bQ�_ 8�2Z�I 13 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: N t l iCLO,\ '� . ►�I nth G� �c c_. I� y Name Signature 8 20 /13 Date Cemetery Sexton Certification: 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. A R }DIIIAMbi rOr'. � State of Florida, Department of Health, Bureau of Vital Statistics ELT BURIAL TRANSIT PERMIT DATE PRINTED: August 19, 2013 TRACKING NUMBER: 2013118707 1. DECEDENT INFORMATION Name of Deceased Date of Death MADISON JANE SMITH August 17, 2013 Place of Death - County City, Town or Location Name of facility, or street address if not a facility DUVAL JACKSONVILLE BAPTIST MEDICAL CENTER 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. WILLIAM B. WHITTAKER F026900 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 -5121 . Q G�� Date Issued: August 19, 2013 Meade Grigg, State Registrar I AUTHORIZATION for CREMATION, DISSECTION, BURIAL -AT -SEA, or HOSPITAL DISPOSITION Authorization given by Medical Examiner District 4 Approval Number: 4. CEMETERY OR CREMATORY Place of Disposition: SEBASTIAN CEMETERY 1—�01 () fttl Method of Disposition: BURIAL Date of Dispositi'o'n: l L 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 CITY OF SEBASTIAN CITY CLERK'S OFFICE 4801 01 RECEIPT v �l V�+ -TV t Name strL� n k- F' Lt" e- r Ci ❑ Cash Date 2U -1 7 `Check# ` 2— No. 001001208001 001501 322900 001501 341920 001501 341910 001501 341930 601010 343800 001501 343805 Amount Paid Sales Tax _ Garage Sales _ Copies /Bid Specs. _ LDCICode of Ordinances _ Election Qualifying Fees _ Cemetery Lots _ LoVNiche / ) , Block , Unit Cemetery Fees _ 4o,)Sccna Total Paid Zo. 00 Initials White - Dept. of Origin • Yellow - Finance • Pink - Applicant FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY C unn SFS y HOW OF AFtlCAN ISLIM 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 STRUNK 49t9t WTCREMATORY FUNERAL HOME: 1623 No. Central Ave. SEBASTIAN, FL 32958 ADDRESS: (772) 589 -1000 PHONE #: (Ch ck One) '^ OPEN BURIAL LOT Lot Is Block LO Unit `T OPEN CREMAINS LOT Lot Block Unit OPEN COLUMBARIUM NICHE Niche Block Unit N S E W BURIAL DATE AND SERVICE TIME: FOR DECEASED: NI G�G�ISor> Gtt`l L Name NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership) bat" b B bl is 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: Name Signature Date Cemetery Sexton Certification: certify that I have checked the ownership information by viewing the owner's deed and confirming with Clerk's office a d th tall fees have been paid: o . 7,-Wo . CerAetdry sexton Da This form to be provided to Clerk's Office by Sexton for permanent record upon completion. MCC ERA" ST HOME OF PELICAN ISLAND Burial rights in the Sebastian Municipal Cemetery lots /niches purchased by me Do-w n 13 i e- h s /5 7o fi e vGk-n JV" v c, Seba.5- i cgg ,FL 3ZY ,5 (Please print name and address of purchaser) 6, Lofs 1,Lt, 15, i (Lot/niche, block, unit description) are intended for interment of the following individuals: Please print name(s): /V1ad (s on Sm t f h 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. ?D' L 3 Signature D e scribed a •swom to before me this 0-12? day of Q��, by who is personally known to e, or has produced as identification. _ �J E IiRE�YSttt� FtW� Notary Pubr , St of Florida �4 ""��•.,�y P 2016 Emotes Jul 16. s ' JAY coma EE 216710 Names of Interred form Oommisst" # l0i %olxy ms"'. W N) ID Lr. U U) � \ CP la, � \ \� /\ \ L J )} � ®r;