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Home My WebLink About4-03-23Name_ oil lB7f' b• Ix—e-flow !!�X B 3 jeJe'5 - Unit Block Lot Date of Mark -out 8 Date of Burial�/�/I Time l ' 3 4 ems✓ �' Name of Funeral Authorized by *SEAWINDS* FUNERAL DOME & CREMATORY 735 S. Fleming Street, Sebastian. Florida 32958 ELt i o -t -f - Do -rye+ Jack 13 uurL t Tra*v,yi� V e�rwubf Ky*r0r W, "i . OA4gCL SC4-?,4 i7T 33ga N. ep"U2,1"&-W)q/ 'BI JD, Ap� 104 C1.eN5ei-v i3e? - ,344?6-7 State of Florida, Department of Health, Bureau of Vital Statistics -- —' BURIAL TRANSIT PERMIT HEALTH DATE PRINTED: March 8, 2017 TRACKING NUMBER: 2017039455 1. DECEDENT INFORMATION Name of Deceased Date of Death ELLIOTT DORSET JACKSON March 7, 2017 Place of Death - County City, Town or Location Name of facility, or street address if not a facility INDIAN RIVER VERO BEACH VNA HOSPICE HOUSE 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. 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: March 7, 2060-505s Date Issued: March 7, 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 CEMETERY �J Method of Disposition: BURIAL Date of Disposition: / 2— EDRS maintains all statutorily required information regarding the death record and related burial transit permit, therefore, returnhig the permit to the county stealth 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 CITY OF SEBASTIAN 10422 ADMINISTRATIVE SERVICES RECEIPT Name SFAwrhros I j"--"0IgCash Date :3.19 ( 0 1 )dCheck #0136-0 0 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 (-�ois*ai 3439c2s c)lc, oe `�/, U0 Total Pai dials Security Dep Held - Amount $ Check # White - Dept. of Origin • Yellow - Admin. Svcs. • Pink - Applicant Funeral Director's Request to City of Sebastian for Burial Opening in Sebastian Municipal Cemetery Contact Information: 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 ctesta (d)citVofsebastl an. org Funeral Home: "�EgeWIWDS /' UNC.CA/ /dCnr/E .vtL -e,,r /e CAS ST�tFEi SL (Check) LotdZ3 Block -6 Unit—Z Open Burial Lot Open Cremains Lot Lot_ Block_ Unit Open Columbarium Niche Niche_ Block_ Unit_ (Circle) N S E W Burial Date and Service Time: Deceased Name: Name and Signature of Lot O or R presentative: (Must provide proper docume ati of ner 7 �7 Print Name natur Date I certify that 1 have determined the o ership 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 Funeral Director: Print Name 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. Cemetery Sexton Certification: Cemetery Sexton Date This form to be provided to Clerk's Office by Sexton for permanent record upon completion. CRY OF SEB" HOME OF PELICAN ISLAND Certificate No. 2499 CITY 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: Elliott Jackson 339 Sebastian Crossing Sebastian, FL 32958 In and for consideration of the sum of $1,000.00 is entitled to full interment rights in the Sebastian Municipal Cemetery for the following lot: Unit 4, Block 3, Lot 23 of the Sebastian Municipal Cemetery, as maintained on file in the records of the City Clerk for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. CONVEYED THIS 1st day of April, 2016. CITY OF SEBASTIAN, FLORIDA �l �ti— - Joseph F. Griffin City Manager ATTEST: Je nette Williams, MMC City Clerk utt 5J�� j HOME OF PELICAN ISLAND City of Sebastian Municipal Cemetery Purchase Receipt To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate regulations, proof of City residency of purchaser or person for whom lot is intended for interment must be provided at time of purchase. JaC)ZS0r) Name(s) Sohl]47'ilir, (i D.SSrnaS 13/vd SMa5han FL 3295(Y 7z Code A Phone Number Name & Residence Address of Intended Occupant if Other Than Purchaser OFFICE USE ONLY Receipt is acknowledged in the sum of: A In . A ,a. ftoX _ Dollars ($ /L0UQ UO ) on this day of 20 6 for the purchase of the following described CemeteryLots) and/or Niche(s). Unit qBlock 3 , Lot(s) Z3 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 Signature of Purcha r I:\W W-DATA\Ms-Cemetery\RECEIPT.doc Interment /W O H Circle One Disinterment TOTAL $ /60Q. 00 City of Sebastian The following documents were provided as Proof of Residency: -5� f}-�YAi n and JLA. f EC CITY OF SEBASTIAN 10065 ADMINISTRATIVE SERVICES RECEIPT Name Mr. Jra-dCS0�1 0Cash Date q-1 — / (O r"Check # 2-30 I] 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 (2nlD 0 3y3Soo Uenlere.,-�bt 10moo Gt4 133 L23 Total Paid LQPO. 00 Initials Security Dep Held - Amount $ Check # White - Dept. of Origin • Yellow - Admin. Svcs. • Pink - Applicant