HomeMy WebLinkAbout4-06-12Unit Y
Block
Lot sz.
Date of Mark -out
Date of Burial% zx/. Time
Name of Funeral Home Al n
Authorized by�
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HOME OF PELICAN ISLAND
Certificate No. 2402
C
ITY OF S-)E-,B-jA, STIAN
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Heriberto & Teresa Perez
994 Clearmont Street
Sebastian, FL 32958
In and for consideration of the sum of $1,000.00 is entitled to full interment
rights in the Sebastian Municipal Cemetery for the following lot:
Unit 4, Block 6, Lot 12
of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and
regulations prescribed therefore by the City of Sebastian.
CONVEYED THIS 7th day of January, 2014.
CITY OF SEBASTIAN, FLORIDA
Joseph F. Griffin
Interim City Manager
ATTEST:
Sally A. ' M"aio, MMC
City Clerk
CITY OF SEBASTIAN
CITY CLERK'S OFFICE
RECEIPT
4832
r Pere Z
Name r `e Cash
1 7-/4?
Date ❑ Check#
No.
Amount Paid
001001 208001 Sales Tax
001501 322900 Garage Sales
001501341920 Copies /Bid Specs.
001501 341910 LDC /Code of Ordinances
001501341930 Election Qualifying Fees
601010343800 Cemetery Lots
1006.00
Lot/Niche i L_, Block l• Unit
001501 343805 Cemetery Fees
Q&
150.00
rjv�
To Paid
500.0()
Initials
White - Dept. of Origin • Yellow - Finance • Pink - Applicant
Cm of
HOME OF YELICAN ISLAND
5 . f ,
To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate
regulations, proof of City residency of purchaser or person for whom lot is intended for interment must
be provided at time of purchase. re reSo_
9e- r zrto Perez
Names)
9 q � Cl e a -rrnotl Street S�loas t��� �� J2-g5,5
Address
C7 7J-) 3SS- - gg g.�
Area Code & Phone Number
Name & Residence Address of Intended Occupant if Other Than Purchaser
r.
Receipt is acknowledged in the sum of:
Dollars ($ /6 () 0 , ®U
on this. '-7`A'^ day of aA-,L+ 20 1L( for the purchase of the following described
Cemetery Lot(s) and /or Nic (s).
Unit, Block (o , Lot(s)
OZ
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 -1 $2
Vase and Ring for Niches (cost)
Temporary Marker Preparation & Installation
Signature of Purch e
:1ww- DATA \Ms- Cemetery\R FCFI pT. dor_.
Opening & Closing
Interment
S 15o.00
/W O H
Circle One
Disinterment
T1 V AT A l L $ 1150,6D
JZ4�i�— 6Ajilk�L-01Z
!"1
ity of Sebastian
The following documents were provided as Proof of
Residency:
and
Fo' nFrr�ratEvr nF State of Florida, Department of Health, Bureau of Vital Statistics
BUR IAL TRANSIT PERMIT
DATE PRINTED: January 8, 2014 TRACKING NUMBER: 2014002062
1. DECEDENT INFORMATION
Name of Deceased Date of Death
EVANGELINA PEREZ - ALFARO January 6, 2014
Place of Death - County City, Town or Location Name of facility, or street address if not a facility
INDIAN RIVER VERO BEACH INDIAN RIVER MEDICAL CENTER
Name and Address of Funeral Home /Direct Disposal Establishment Fla. Lic. No. /Reg. No. Phone Number
SEAWINDS FUNERAL HOME F073380 F073380 (772) 589 -1933
735 SOUTH FLEMING STREET
SEBASTIAN, FLORIDA, 32958
Funeral Director /Direct Disposer Fla. Lic. No. /Reg. No.
ANTHONY GABBARD F044749
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: 2014- FO73380 -5006
Date Issued: January 6, 2014
L� �7 j
Meade Grigg, State Registrar j
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
Sep u14 euUS e:13PM COS CEMETERY 7722289927 p.2
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL. CEMETERY
..,,,
SE •
MOMS V ?Jl1CAN KUNG
For information contact:
Kip Kelso - Cemetery Saxton
Sebastian Mtmfcipal Cemetery
(772) 588 -2545
City cient w Office
City HAIL, 1225 Main Strset
Sebastian, FL 32958
01flce (772) 388 -8215 or 388.8214
Fax. (772) 589 -5570
FUNERAL NAME: c n7�i
ADDRESS: -7-3S- S
W
PHONE #t: 7 ?�Z S`g -- / f 33 v • .. 3 -r- 95-9
One)
PEN BURIAL LOT Lot ^�Elock �e Unit
PEN CREMAINS LOT Lot ----8lock Unit
PEN COLUMBARIUM NICHE Niche Block "! —'Unit
BURIAL DATE AND SERVICE TIME: % — q— 2-`---,) q
FOR DECEASED: Ey ,+nJe 4 L '�. v- o
Name
NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE:
(Must provide proper documentation of ownership)
Name gnature Date
I cerl)iy that J have determined the ownership of the above described ;Ile that ail site fees and
administrative fees have been paid and authorize opening of some
NAME AND SIGNATURE.OF LICENSED FUNERAL DIRECTOR.
f
Name ignature ap 1e
--- ...--- ------------ -------............. , .....4— ........._....._............ . ... .. ................ ......
Cemetery Saxton CoAlfication:
I certify that I have checked the ownership information by viewing the owner's deed and confirming
with Clerk's office and th t loll fees have been paid
4//
Cem tery xt Date
his form to be provided to 6Ierk's Office by Sexton for permanent record upon completion