HomeMy WebLinkAbout4-03-09,O
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Unit
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Date of Mark -out &/^'�/i5��
Date of Burial GAA I of � ^ Time
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HOME OF PELICAN ISLAND
Certificate No. 2463
JTY OF SEBASTIAN
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Kathleen S. Poff
6111 River Grove Drive
Sebastian, FL 32976
In and for consideration of the sum of $2,000.00 is entitled to full interment
rights in the Sebastian Municipal Cemetery for the following lot:
Unit 4, Block 3, Lot 9
of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and
regulations prescribed therefore by the City of Sebastian.
CONVEYED THIS 26th day of June, 2015.
CITY OF SEBASTIAN, FLORIDA
Joseph F. Griffin
City Manager
ATTEST:
Sally A. aio, MMC
City Clerk
DANIEL R. POFF
Daniel R. Poff of Micco passed away in Sebastian on Thursday, June 25, 2015 at the age of 66.
Daniel was born March 2, 1949 in Cincinnati, Ohio and has been a resident of Micco and Sebastian since
1990. Prior to retirement he was self-employed at PoffJanitorial Services in Cincinnati, OH. He was a
veteran of the U.S. Army during the Vietnam era. Daniel was a member of the Moose Lodge 1767 of
Micco, FL and the Eagles of Indian River Lagoon 4527 also of Micco. He loved boating and Bud Lite.
Members of his family include his loving wife of 26 years Kathleen Poff of Micco, FL; two daughters Julie
Montgomery of Monroe, OH, Jill Deirs and her husband Richard of Marysville, Ohio; step -son Johnny
Human of Cincinnati, OH; brothers Joseph, Timothy, and Todd all of Cincinnati, OH; two sisters Rebecca
Rieger of Cincinnati, OH and Kristine Bougie of Middletown, OH; and six grandchildren. He was preceded
in death by his brother David Poff.
CITY OF ff
HOME OF PELICAN ISLAND
City of Sebastian Municipal Cemetery Purchase Receipt
To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate
regulations, proof of City residency of purchaser or person for whom lot is intended for interment must
be provided at time of purchase.
S
Name(s)
r�Ica vuuc U r I Jul IC INUII IUCI
Name
Residence Address of Intended Occupant if Other Than Purchaser
OFFICE USE ONLY
Receipt is acknowledged in the sum of:
.4. -_ LL_- _ . a.. - rLo/
r,r
lars ($ Z000. 10 o
on this Z(04-'% day of I'LL411t 206 for the purchase of the following described
Cemetery Lot(s) and/or Niche(s).
Unit _', Block 3 , Lot(s) 9 VM 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 1540,040 -1W O H
Circle One
Vase and Ring for Niches (cost)
Temporary Marker Preparation & Installation
Signature of Purchaser
I:\WW-DATA\Ms-Cemetery\RECEI PT.doc
Interment
Disinterment
TOTAL $ 7-166-010
ity of Sebastian
The following documents were provided as Proof of
Residency:
CITY OF SEBASTIAN
FINANCE DEPARTMENT RECEIPT 9905
Name// . a rl I f`f'.-n A 7T ❑ Cash
Date (7 ' 2-& - 15 JfCheck #5N
❑ Credit
Amount Paid
001001 208001 Sales Tax
001001 220000 Security Deposit -
001501 362100 Taxable Rent -
001501 362150 Non -Taxable Rent -
450010 369900 Airport Badge
001501 329500 Alarm Permits
001001 218010 CobraServe
001501 354100 Code Enforcement Fines
001501 347557 Community Center Revenue
001501341920 Copies
001501 369900 Miscellaneous Revenue
001501 359000 Other Fines/Forfeitures
001501 351140 Parking Citation
001501 342100 Police Security Services
00/010 3-3£-05 0g63C.41-10 2000,v0
U0�501 93�3-ka5 61/G 150,00
Total Paid u67401W
Initials
White - Dept. of Origin • Yellow - Finance • Pink - Applicant
State of Florida, Department of Health, Bureau of Vital Statistics
- -- — BURIAL TRANSIT PERMIT
HEALTH DATE PRINTED: June 29, 2015 TRACKING NUMBER: 2015098826
1. DECEDENT INFORMATION
Name of Deceased Date of Death
DANIEL R POFF June 25,2015
Place of Death - County City, Town or Location Name of facility, or street address if not a facility
INDIAN RIVER SEBASTIAN SEBASTIAN RIVER MEDICAL CENTER
Name and Address of Funeral HomelDirect 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.
DAVID W. WALLACE F046853
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: 2015-FO73380-5154
Date Issued: June 26, 2015
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 q _
Method of Disposition: BURIAL Date of Disposition: ( I(7
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-1,01 1, Florida Administrative Code