HomeMy WebLinkAbout3-76-10Name.Owl
s
Unit �s
Block Z6
Lot -
Date of Mark -out - •
Date of Burial
• Time 12 9"00Gdo jeL •
Name of Fune
Authorized by
State of Florida, Department of Health, Bureau of Vital Statistics
- --- BURIAL TRANSIT PERMIT
HFAI_TH DATE PRINTED: August 10, 2016 TRACKING NUMBER: 2016123354
1. DECEDENT INFORMATION
Name of Deceased Date of Death
ISABELA GAMEZ August6,2016
Place of Death - County City, Town or Location Name of facility, or street address if not a facility
INDIAN RIVER FELLSMERE 142 SOUTH CYPRESS STREET
Name and Address of Funeral Home/Direct Disposal Establishment Fla. Lic. NodReg. 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: 2018-F073380-51 a4
— Date Issued: August 8, 2016
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 , ` '
Method of Disposition: BURIAL Date of Disposition: c' j
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 Cade
=c.
03/12/2012 10:30 7722287079 COS AIR BLDG PAGE 01/01
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
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For information contact:
Kip Kelso - Cemetery Sexton
Sebastian Municipal Cemetery
(772) 589-2545
FUNERAL HOME:
ADDRESS:
City Clerk's Office
City Hall, 1225 Main Street
Sebastian, FL 32958
Office (772) 388-8215 or 388-8214
Fax: (772) 589-5570
fYE'.yiN6 ._5'T•
F/
PHONE #:
(Che ne)
OPEN BURIAL LOT Lot /O Block 76 Unit
OPEN CREMAINS LOT Lot Block Unit
OPEN COLUMBARIUM NICHE Niche Block Unit
N S E
BURIAL DATE AND SERVICE TIME: Al/6!/S�/ �� G/6 W �(2�✓AwSettv�«J
FOR DECEASED: �141*1EZ-
Name
NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATI
(Must provide proper documentation of ownIn
p
ft �l C-�t.CY i
Name a Date l l
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.
NAME AND SIGNATURE OF LICENSED
Name
Cemetery Sexton Certificatlon:
I certify that 1 have checked the ownership info ation by viewing the owner's deed and confirming
with Clerk's office and that all fees have been paid:
Cemetery Sexton Date
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.
CITY OF SEBASTIAN 10114
ADMINISTRATIVE SERVICES RECEIPT
Name GqmF-.;—Z 0 Cash
Date 2110 1 7YCheck # 47 6
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
0&//J/
/
01501 329100 Zoning Fees
V1 /T 3 /71 %X7-1 O
AC�tS 01 �34a gc -0/c.-
Total Paid.
n 'als
Security Dep Held - Amount $ Check #
White - Dept. of Origin • Yellow - Admin. Svcs. • Pink - Applicant