HomeMy WebLinkAbout3-37-13Name
Unit
72
Block 37
Lot 1-3
Date of Mark -out 6 a /6 s 2-S_
Date of Burial
Name of Furneral Home
Authorized by
Funeral Director's Request to City of Sebastian for Burial Opening in
Sebastian Municipal Cemetery
Contact Information:
City Clerk's Office
Cathy Testa
City Hall, 1225 Main Street
Sebastian, FL 32958
Phone (772) 388-8209
ctesta(a),c i tv ofsebast i an . o ra
Funeral Home: Strunk Funeral Home
Address:1623 N. Central Ave, Sebastian, Florida 32958
Phone: 772-589-1000
(Check)
n Open Burial Lot
Open Cremains Lot
Open Columbarium Niche
Burial Date and Service Time: 06/17/2025
Deceased Name: Richard Vincent D'Amico
Unit Block,_7 Lot_�t %,>
Unit Block Lot
Unit Block Niche
Name and Signature of Lot Owner or Representative:
(Must provide proper documentation of ownership)
Print Name Signature Date
Address Phone Number
I certify that I have determined the ownership. of the above -described site that all site fees and
administrative fees have been paid and autho ''zed opening of same.
Name and Signature of Licen uner irector:
Sandra Mastrando 06-13-2025
Print Name star Date
I certify that I have checked-ie ownership information by viewing the owner's deed and
confirming with Clerk's Office and that all fees have been paid:
Cemetery Certification:
amZae�teqry Date
This form is to be provided to Clerk's Office for permanent record upon completion.
State of Florida, Department of Health, Bureau of Vital Statistics
BURIAL TRANSIT PERMIT
HEALTH DATE PRINTED: June 17, 2025 TRACKING NUMBER: 2025111759
1. DECEDENT INFORMATION
Name of Deceased Date of Death
RICHARD VINCENT D'AMICO June 12, 2025
Place of Death - County City, Town or Location Name of facility, or street address if not a facility
BREVARD BAREFOOT BAY 805 BOUGAINVILLEA CIRCLE
Name and Address of Funeral Home/Direct Disposal Establishment Fla. Lie. No./Reg. No. Phone Number
STRUNK FUNERAL HOME-SEBASTIAN F041870 F041870 (772) 589-1DOD
1623 N CENTRAL AVE
SEBASTIAN, FLORIDA, 32958
Funeral Director/Direct Disposer Fla. Lic. No./Reg. No.
MARY A. KOPCHAK F486444
Medical Verification Statement
Staff at the certifying physician's office, was contacted on 06/13/2025 by the funeral director listed above; he/she indicated that
ANKIT POPATLAL PATEL, certifying physician, will complete and sign the medical certification of cause of death within 72
hours.
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: 2025-FO41870-5094
�--- Date Issued: June 13, 2025
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 MUNICIPAL 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 325E. 10/12
64V-1.011, Florida Administrative Code