HomeMy WebLinkAbout4-06-02Certificate No. 2392
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Warren D. & Eileen T. Johnson
202 Dickens Avenue
Sebastian, FL 32958
In and for consideration of the sum of $2,000.00 is entitled to full interment
rights in the Sebastian Municipal Cemetery for the following lots:
Unit 4, Block 6, Lots 1 & 2
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 27th day of September, 2013.
CITY OF SEBASTIAN, FLORIDA ATTEST:
,All Minner Sally . Maio, MMC
ity Manager City Clerk
Name L ✓pICN 50 _Al- 3 flIeS
Unit
Block 6
Lot
Date of Mark -out
Date of Burial �� �i6� Time
Name of Funeral Home --5' ,euy
Authorized by
EILEEN T. JOHNSON
Mrs. Eileen T. Johnson, 67, died September 23, 2013 at her residence
in Sebastian. She was born August 29, 1946 in McKeesport, PA and
lived in Sebastian since 1991.
She retired as a Registered Nurse last serving at Indian River Estates
in Vero Beach. She was a member of St. Sebastian Catholic Church.
Survivors include her husband, Warren D. Johnson of Sebastian;
daughters, Stephanie Cravenho (Steve) of Sebastian and Christine
Grieco (Peter) of Stuart; granddaughters, Paige and Taylor Cravenho
both of Sebastian.
CITY OF SEBASTIAN
CITY CLERK'S OFFICE 4821
RECEIPT
Name S'b—(ky\,l- /�10hn.SGn
Date q- 2 7- 3
No.
❑ Cash
Artheck# is 4
Amount Paid
001001
208001
Sales Tax _
001501
322900
Garage Sales _
001501
341920
Copies /Bid Specs. _
001501
341910
LDCICode of Ordinances _
001501
341930
Election Qualifying Fees _
601010
343800
Cemetery Lots _
Lot/Niche—,�- Block? Unit
001501
343805
Cemetery Fees _
Ci u�A Total Paid L .
Initials
White - Dept. of Origin • Yellow - Finance • Pink • Applicant
CITY OF SEBASTIAN
CITY CLERK'S OFFICE 4820
RECEIPT
Name -� / r ��S �J U ►�J G n ❑ Cash
Date q' Z + 7 - /3 , Check# q0 7L
No.
Amount Paid
001001
208001
Sales Tax
001501
322900
Garage Sales
001501
341920
Copies /Bid Specs.
001501
341910
LDCICode of Ordinances
001501
341930
Election Qualifying Fees
601010
343800
Cemetery Lots
/ J
Lot/Niche Block Unit 14
, ,
001501
343805
Cemetery Fees
4d (� '^ '� Total Paid
Initials
White - Dept. of Origin • Yellow - Finance • Pink • Applicant
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
0-
HOME OF VEUCAN ISIANR
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 -8294
Fax: (772) 589 -5570
FUNERAL HOME: STRUNK FUNERAL HOME & CREMATORY
ADDRESS: 1 0- 32959
PHONE #: (M)SWimo
(Ch k One) , II
+
OPEN BURIAL LOT Lot 2 Block � Unit `
OPEN CREMAINS LOT Lot Block Unit
OPEN COLUMBARIUM NICHE Niche A �JCBlock Unit
BURIAL DATE AND SERVICE TIME N T W C�
FOR DECEASED: I-1 k&—) I • J )hns(X)
Name
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.
NAME AND SIGNATURE OF LICENSED FUNE DIR C OR:
Name Signature g 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:
�, eddo ��4 . C?h r//
Cem ery ext n Date
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.
FLORLD }DFPARTGiU1i r]F', r+ State of Florida, Department of Health, Bureau of Vital Statistics
EA l BURIAL TRANSIT PERMIT
DATE PRINTED: September 23, 2013 TRACKING NUMBER: 2013135890
1. DECEDENT INFORMATION
Name of Deceased Date of Death
EILEEN T JOHNSON September 23, 2013
Place of Death - County City, Town or Location Name of facility, or street address if not a facility
INDIAN RIVER SEBASTIAN 202 DICKENS AVENUE
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 -5129
Date Issued: September 23, 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 —T � Q
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