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HomeMy WebLinkAbout4-07-01Name '146 q le 6 / :9:9 Unit Block Lot AV. Date of Mark -out /" /G i1Ifr 'ec Date of Burial ez3a// 4 Time Name of Funeral Home Authorized by /!.'o011 . iL :: T 5fe. Oct 25 17 02:13p Seawinds Funeral Home 772-589-1939 p.1 Funeral Director's Requestto City of Sebastian for Burial Opening in Sebastian Municipal Cemetery Contact Inforination: Kip Kelso, Cemetery Sexton Sebastian Municipal Cemetery Phone (772) 589-2545 Fax (772) 228-9927 City Clerk's office Cathy Testa City Hall, 1225 Main Street Sebastian, FL 32958 Phone (772) 388-8209 �.iiES'ia(�Ciyo seb2saan-oro (Check),,L/ Open Burial t.nt Lot � Block_Z-- Unit! Open Cremains Lot Open Columbarium Niche Burial Date and Service Time:G o Deceased Lot Block Unit Niche Block Unit (Circle) N S E W 2.01 NAm Fun e2a902� Sf S�a� Name and Signature of Lot Owne orRepresenta - e: ((pJynlustprovdepropperdacMen ofownersb' KoSenn LI WI.,11 /o LaLS 7 Print Name'gnature Date I certify that I have determined the ownership of tie above described site that all site fees and administrative fees have been paid and authorized opening of same. Name and Signature of Licensed Fun aI Director: ila lepra K�t/EF~ �� (U a5 a,o Print Name Signature Date I certify that I have checked the ownership information by viewing the owners deed and confirming with Clerk's Office and that all fees have been paid: Cametory Sexton Certification AIAIJ 0/, r //,�Z CenXAMSextan Date This form to be provided to Clerk's Office by Sexton for permanent record upon completion. My or SEBAS-TLAN HOME OF PELICAN ISLAND Certificate No. 2550 CITY QB SEBASTIAN Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Rose Marie Whelan 48 Sunset Drive 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 lot: Unit 4, Block 7, Lot 20 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 24th day of October, 2017. CITY OF SEBASTIAN, FLORIDA Joseph F. Griffin City Manager ATTEST: W J nette williams;, MALE City Clerk - Funeral Director's Request; ;o Cit; of Sebastian for Burial OP-aning in Sebastian Municipal Cemetery Contact information: Kip Kelso, Cemetery Sexton Sebastian Municipal Cemetery Phone (772) 589-2545 Pax (772) 228-9927 City Clerk's Office Cathy Testa City Hall, 1225 Main Street Sebastian, FL 32558 Phone (772) 388-8209 (Check Open Burial Lot Loi 2-c Block Unit Open Cremains Lot Open Columbadurn niche Burial Date and Service Tiim�e Deceased name: , i Jif A ) <Z Lot Block Unit Niche Block Unit (Circle) N S E VV AM ci h r iiaavie and Signature of Lot C3wree ar Nepresenta 've: Must provide proper documen i of owners " i Print Name gnature 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 authorized opening of same. Name and Signature of Licensed Fune�al Director: Print Nameq. Signature Date 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: Cerneten7 Sexton Certification: Cemetery Sexton Date This form to be provided to Clerk's Office by Sexton for permanent record upon completion. an or EBAs S �" HOME OF PELICAN ISLAND City of Sebastian Municipal Cemetery Purchase Receipt 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 timer�,�•�,urchase. ogc AI A-42 l e Name(s) 8 St c�)5e-r �R . S l-6-ST-1AIJ, FL. 3-ge?V Address & Phone N 6.uS W d L4nj. Name & Residence Address of Intended Occupant if Other Than Purchaser OFFICE USE ONLY Receipt is acknowledged in the sum of: —TO or�4 � Sr4nl�l In N3 '©/[od "z Dollars ($ --2000 co ) on this day of JC/7V62rL , 20� for the purchase of the following described Cemetery Lot(s) and/or Niche(s). Unit _—, Block �7 , Lot(s) 010 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 Sig ature of Purchaser I:\W W-DATA\Ms-Cemetery\RECEIPT.doc Interment /W O H Circle One Disinterment TOTAL $ P� 000. 0 0 City of The following documents were provided as Proof of Residency: Name CITY OF SEBASTIAN 10934 ADMINISTRATIVE SERVICES RECEIPT Date IL) ja`+heck# ❑ Credit Amount Paid 001001 208001 Sales Tax 001001 220000 Security Deposit 001501 362100 Taxable Rent 001501 362150 Non -Taxable Rent 450010 369900 Airport Badge 001001218010 CobraServe 001501 354100 Code Enforcement Fines 001501 347557 Community Center Revenue 001501341920 Copies 001501 351140 Parking Citation 001501 342100 Police Security Services 001501 329200 Site Plan Review 001501 329300 Subdivision/Plat Review 001501 329100 Zoning Fees 1016- 34-3 96P LFTs- 44CC: o. -T 0,,7 i -T- 4 e i 1G 7 LCT- A lop /� "I �./ Total Pai Initials White - Dept. of Origin • Yellow -Admin. Svcs. • Pink - Applicant State of Florida, Department of Health, Bureau of Vital Statistics 17P,"" BURIAL TRANSIT PERMIT HEALTH DATE PRINTED: October 24, 2017 TRACKING NUMBER: 2017168057 1. DECEDENT INFORMATION Name of Deceased Date of Death AUGUSTINE D WHELAN JR October 23, 2017 Place of Death • County City, Town or Location Name of facility, or street address if not a facility INDIAN RIVER SEBASTIAN 48 SUNSET DRIVE Name and Address of Funeral Home/Direct Disposal Establishment Fla. Lie. No./Reg. No. Phone Number SEAWINDS FUNERAL HOME F073380 F073380 (772) 589-1933 735 SOU74i FLEMING STREET SEBASTIAN, FLORIDA, 32958 Funeral Director/Direct Disposer Fla. Lie. NoJReg. No. Kathleen Kauffman F047386 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: 2017-FO73380-5208 �-- Date Issued: October 23, 2017 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 MUNICIPAL 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