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Home My WebLink About1-08-18Name Unit Block Lot Date of Mark -out Date of Burial 7/ AL �3 Time � cc Name of Funeral Home wit N Authorized by �� W M CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT `+ V I 7 /, 81 C� Name. arl z yl cs --e--o Date q- 2-7- ( 3 No. 001001 208001 Sales Tax 001501 322900 Garage Sales 001501 341920 Copies /Bid Specs. 0 Cash //-- ; Check # 628 Z 001501 341910 LDCICode of Ordinances 001501 341930 Election Qualifying Fees 601010 343800 Cemetery Lots LoUNiche 3 Block E , Unit 001501 343805 Cemetery Fees Amount Paid G� Total Paid t-/ nn - UG Initials White - Dept. of Origin • Yellow - Finance • Pink • Applicant FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY n� HOME OF PELICAN 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. centrat Ave. ADDRESS: SEBASTIAN, FL 32958 PHONE #: (772) 539-1000 (Ch ck Ones OPEN BURIAL LOT Lot Block OPEN CREMAINS LOT Lot Block OPEN COLUMBARIUM NICHE Niche Block BURIAL DATE AND SERVICE TIME i l-tl, -aS N FOR DECEASED: A I 1 Ct CV Name jrd \11*d <tCS Unit Unit Unit W t3 -a-N00INJ --.t�l aop oouy 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. ME AND SIGNATURE OF LICENSED FUNERAL DIRECTOR: M cUr�U- J VU IZt�cl�a,a V", ( 2v 13 Name Signature I Dat Cemetery Sexton Certification: certify that l have checked the ownership information by viewing the owner's deed and confirming with Clerk's office ao that all fees have been paid: 4 a, , - 1,1Z 5-1 deWete4 Sexton Date This form to be provided to Clerk's Office by Sexton for permanent record upon completion. FLORL6. }Iy��arb{gvii7E' ' State of Florida, Department of Health, Bureau of Vital Statistics HE BURIAL TRANSIT PERMIT DATE PRINTED: September 17, 2013 TRACKING NUMBER: 2013132935 1. DECEDENT INFORMATION Name of Deceased Date of Death ALICE CRAWFORD VICKERS September 17, 2013 Place of Death - County City, Town or Location Name of facility, or street address if not a facility ALACHUA GAINESVILLE WOODLAND CARE CENTER OF ALACHUA 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. R. MARSHALL VOYLES JR F043488 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 -5126 2G /� Date Issued: September 17, 2013 Meade Grigg, State Registrar I 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 1 13 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 JUL-1Bi2012 WED 11 : 15 AM MCB Bristol Highway FAX No. 423 232 5134 P. 003/005 From:The UPS Store 4239 7725899175 07/17/2012 10:56 #500 P.002/007 ED • • cam R\ HOME OF PELICAN ISUANO Burial rights in the Seba�s}tan Municipal Cemetery lots/niches purchased by me tct tit t V,ck6c s I o h -vGiS t;r Gaper s011,40p( (Please print name and address at purchaser) T P 5"1 60 1 (Lot/niche,block, unit description) are intended for interment of the following Individuals: Please print name(s): 1 (1) L (8) .Lik..e!'S ln (11 ) Vic tc2.•'-3 004— (2) .y 1ncr■.4. i64er5 (7) 6.E?cy- .Z 't-. . 5 (12) L3 Kea-G ]- Vic:Ke.- (3)ref( 1 ono— `/i GK.e .-5 (8) S'""- ' kI [ 4YS (13) ,wtt--i VI t:ge-r'S (4) V tr cam- V i (�+�r-� (s) (14) ✓,L it.Q. 3 rh4 (5) i CY--t rs l (10) . • -di 't V Yr-k-2r5 (15)y'c__er-, r bo 4 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 h re d u tF1 a arms of this agreement.T Z nature Date n4 day or _Qty ZO 1?! e Subscribed V • before me this t - me, or . has produced 1 who Is personalty known 10 me, .._ N t4antilioalion. ````.`�'�ALErt-,,.,',Ir. Notary Public.Slate of•lrlerfda T� :.:1.1 ..." STATE •:`G. O! OF wm.s otam.r>eo twr^ _ i TENNESSEE• m ti,. NOTARY t ,,�/ysti2, GT° • JUL-18;2012 WED 11 : 15 AM MOB Bristol Highway FAX No. 423 232 5134 P. 004/005 From:The UPS Store 4239 7725899175 07/17/2012 10:56 #500 P.003/007 02 ono HOME Of PELICAN I5lAND Burl I rights in the'S�ebastiian Municipal Cemetery lots/niches purchased by me ;C ub tt U 4ici15 (65" I uc er )40i: . A.k..teo C,I 't T133 ‘7(O1 (Please print name and address of purchaser) I-AA- bo d-a 1 bloc-w- a Or 14- 1 (Lot/niche,block,unit description) are intended for interment of the following Individuals: Please print name(s): 24 6 col it i 4:--, pi - (II 6 i) Ivy,-.t t�rk.i c P1(�. w") 1(ic.k.z�.6 pla4-- (frtGT)) vier—e., faLtl-� 06.2,. - a..4 s -r1 ?rc-.3--).) Vide..e,5 p)&-- id) ie 111 r'› ,1 ,•4- ( - ) r -Let:Sa~n 7)Cam) YrcR-k-mss 4)104-- (') /4 - au, IGr-Qt'S ' ) .. -;ri • •c r\ (.7r iDi' 3o fibug1As ric,k.. , (5 or r�0 e- . Ir ( , ) Oe' 1` i uwl'S (7 406))` ,49hi (.. V;c4,24 -5 se. • 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 reievfint probate or other court documents. t h d u "lit er terms of this agreement, Signature Date ubacribed and awortt in belong me this ay of 1� by �o i,,kr•own has i ivducea -r� i . sj 1 f p'- as Ilona! '��` � ��T!, Nolary Public.Mate ot,FJorida =9� 44 pO "" of Intoned four+ -S V. ttp`t'F i JUL-18-2012 WED 11 : 15 AM MCB Bristol Highway FAX No. 423 232 5134 F. UUS/UU5 From:The UPS Store 4239 7725899175 07117/2012 10:57 #500 P.0041007 6.1.7;. ) oea 4101BP NOME OF PELICAN ISLAND Burial rights In the bastien Municipal Cemetery lots/niches purchased by me M,t h Wl E 1 CC1t 5 165 Ti'dW 1.AF yp Ina6c,d CI `( T7 (Please print name and address of purchaser) Lor 3 t `$irk 8' Can`,-1- I (Lot/niche,block, unit description) are intended for interment of the following individuals: Please print name(s): -4' ( I '�,.1 . ;c1e-4*-s (• 301 thw• 41 4- (11 ) (if ] - 'C, , . c.}.- (7/ n s a • (12) (�3.--) V►c -ers 0.0.1_ ( <a tpFC)5he1 4-1 r� (13) _ (KA LikA.Asan (0104/ (14) r7 ( VtCY-j 5 c10t- 926 (t'i3 L-piu%s)pk 4' (16) 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 d and nd t d the terms of this agreement. -7 - 17 - / Z--- Signature Date S� to before me Mils l' _day 7,..."•.. , by rnlr�/ii � who ie personal)- k �ipr has piodd.t.2 Dl- 0' S otLt_aelLe 3. as Identification. � ••.;<�)■ Notary Public. too r<J _ *i kilt i c_ T SS - cpnAOq 6F Names of Intend tom ;'• `64/C+1' .. 4f: