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CITY C+
HOME OF PELICAN ISLAND
Certificate No. 2492
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:
Isabelle Cox
581 Quarry Lane
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 40
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 11th day of February, 2016.
CITY OF SEBASTIAN, FLORIDA
Joseph F. Griffin
City Manager
ATTEST:
Sally .�/Maio, MMC
City Clerk
State of Florida, Department of Health, Bureau of Vital Statistics
BURIAL TRANSIT PERMIT
�Lf `- DATE PRINTED: February 9, 2016 TRACKING NUMBER: 2016021590
1. DECEDENT INFORMATION
Name of Deceased Date of Death
HERMAN THOMAS COX February 8, 2016
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 Home/Direct Disposal Establishment Fla. Lic. No./Reg. No. Phone Number
STRUNK FUNERAL HOME- SEBASTIAN F041870 F041870 (772) 589-1000
1623 N CENTRAL AVE
SEBASTIAN, FLORIDA, 32958
Funeral Director/Direct Disposer Fla. Lic. No./Reg. No.
TIMOTHY W. MARVIN F022789
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: 2016-Fo41670-5019
�— Date Issued: February 9, 2016
State Registrar
3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL -AT -SEA, or HOSPITAL DISPOSITION
Authorization given by Medical Examiner District 19 Approval Number:
4. CEMETERY OR CREMATORY
Place of Disposition: VERO BEACH CREMATORY 4 0
Method of Disposition: CREMATION Date of Dispositio :
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
CITY OF SEBASTIAN
FINANCE DEPARTMENT RECEIPT J
Name Lffiba Q ax J Cash _
Date 2/11/16 2 Check #320___
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
001001218010
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
601010
343305
03ebm y lot
1,000.00
001501
3�4-W-13_
_
150.00
^fin
Total Paid
1,150.00
Initials
White - Dept. of Origin • Yellow - Finance • Pink - Applicant
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
FUNERAL HOME
For information contact:
Kip Kelso Cemetery Sexton
Sebastian Municipal Cemetery
(772) 589-2545
City Clerk's Office
City Hall, 1225 Main Street
Sebastian, FL 32958
Office (772) 388-8215 or 388-8214
Fax: (772) 589-5570
Strunk Funeral Home and Crematory
ADDRESS: 1623 North Central Avenue, Sebastian, Florida, 32958
PHONE#: 772-589-1000
(Check One)
XXX OPEN BURIAL LOT Lot 40 Block 3 Unit 4
OPEN CREMAINS LOT Lot Block Unit
OPEN COLUMBARIUM NICHE Niche Block Unit
N S E W
BURIAL DATE AND SERVICE TIME77E) L..,, _--bVICQ IIS P-)�
FOR DECEASED. Herman Thomas Cox
Name
NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE:
(Must provide proper documentation of ownership)
JX
Isabelle Cox2� 2/10/2016
Name Signature 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 authorize opening of same.
NAME AND SIGNATURE OF LICENSED FUNERAL DIRECTOR:
Tim Marvin
Name
Signature
2/10/2016
Date
Cemetery Sexton Certification:
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:
/Ikl� �i_ A_IZL��a 2_Z -2_,1e16
Cemet ry S &ton Date
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.
Vero Beach Crematory, LLC
1830 Wilbur Avenue
Vero Beach, Florida 32960
We hereby certify that these are the cremated human remains of --
Herman Thomas Cox
February 8, 2016 February, 112016
(Date of Death) (Date of Cremation)
Strunk Funeral Home and Crematory Sebastian, Florida
(Funeral Home in Charge) (City and State)
4388 By:
(Cremation ID Number)remator Signature)
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08/29/2016 16:28
HOME OF PELICAN
Sebastian Cemi
Ph# 772-589
Fax# 772-228
Site Plan for Marker
#5920 P.001/001
Type & Si
Name
His
ze of Marker:
ierman T Cox Hers
X
I.
DOB:
DOB:
3
I�
DOD: 2
'08/2016
DOD:
Unit:
4
•t:
Block:
3
Block:
Lot:
40
Lot:
Size Foundat'.
1' x 2'.. ...... I.... Dry rnix,
of concre
Larger than 1I' x 2'...............................Formed
Approved t y: It -
Marked oul by: .C -
Foundation Poured by:_
a
grass marker.
base.
6-