HomeMy WebLinkAbout4-45-26"1622
NO.
THIS INDENTURE MADE ~s llth dar of May A.o., 15 98 ,
.................................... ~ances..T...S.occi ....................................................................
126 Midvale Terrace
........................................ Sebastian,..ES- 3Z9~8 ............................................................
c~,.~, or .. ~9d:$~-, .R.$.3~.r, ........................ ,.-I si.t, or ..... ~'~9~.~-~1.a. ........................................
Thai t;~ Grantor for and in con~d~,afion of the sum of $ . . .6.0.0. :..(~? ................ to It in hand ~mid, tho ,~ceipt whe{eof i,~,with ac-
26,27,28 45 4
Name
Unit
~o~ ~r
Bloo~ ~Jsr~''
Date of Mark-out
Date of Burial
.ame of Funer_a~Ho~)
Time
Paid by CEMETERY Receipt No ................. Dated ..............................
List Price $..~.0~.. ,..0,0. ........ Maximum No. Burial S.ces .................
600 · O0 Monument permitted .......................
Net paid $ ..................
NO.
,1622
(Data above this llae for City p~eeord ouly)
~, Department of Health, Vital S ics
Fi, PJDADEPARTMENTOF ,' . St FIoridacATiON FOR BURIAL-TiaA SIT PERMIT
...... ~PPLJ
(TYPE)
1. Name of First . Middle Last ..... I Date Month Day Year
Deceased ' ' ~ ' D°fthea
Rose Titello 10 / 17 / 99
2.CountyPlace of Death City, Town or Location Hosp.Name or°f (if neither, give street address)
Indian River. Roseland Inst. Sebast an River Medical Center.
3. Name nfMeqical ..... 7965 Bay Street, IPhone Number
Certifier Pedr° A. Espat: M':D. : Address
[-~Medical Examiner ~--~Physician Sebast an, FL I (561} 589-5600
4.EstablishmentName of Funeral Home/Direct. Disposal Address1623 N. Central AVe. Fla. Lic. No./Reg· No. Phone No. (Area Code)
Str'unk Funeral Home Sebastian, FL I 1228 1{561} 589-1000
5. Check a. [] The medical ~ertif~cation has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. [] Pa~ was contacted on 10/18/99
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr.. Espat will complete and sign the medical
certification of cause of death within 72 hours. .
c. [] / was contacted on He/she verified that
- ~ F/ , Medical Examiner, will complete and sign the
I ce/,t, ification of caqs~ o[~ath within 72 ho~rs.
6. Fucera, D,rector/ / / / ~.atura/' j~ ~.E.,o.,Reg.,o. Date S,gneq
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No.1228-99-0477
[] A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has
been con!acted by the funeral director and will not be a~le to complete the medical cortification of cause-of-death section of the death certificate within
72 hours.~
~,Jo extension of time for filing the death certificate has been requested.
........ · . , . -°. DateCe ific te.
SubregistrarSignature ~ Issued:ih ¢9 Due:
AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA
Approval Number: : Date
Medical Examiner, , gave authodza~on by telephone to
Funeral Director/Direct Disposer. Date
The Medical Examine~s approval must be obtained before disposal by any of the abose methods. A waiting period of 48 hours after death is
required for all cremations.
Method of Disposition:
~BURIAL
'-]CREMATION
Signature of Sexton
or Person-in-Charge
CEMETERY OR CREMATORY
Place of Disposition >//~/~ ~7~-~ ~.~ ?
E]STORAGE Date of Disposition
}
This permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Dimctor/IDirect Disposer when there is no Sexton and retur!~ed
within 10 days to the local County Health Department in the county where disposition occurred.
THE SEBASTIAN CEMETERY
Citg of Sebastian
Sebastian, Florida
RECEIPT IS BEREB¥ ACKNOWLEDGED OF THE SUM OF;
described Ce~ter~ ~(s) u~n ~he ~er~ and ~nditions as sta~ed herein;
~scription of Pro~rtg:
Ter~ ~d condi~ions of sal~=
This contract shall be binding upon both parties, the seller and the purchaser,
when approved b~ the owner of the propertg above described.
I, or we, agree to purchase the above described propertg on the terms and
conditions stated in the foregoing intrument:
) <
The Citg of Sebastian agrees to sell the above m~ntioned propert~ to the
above named purchaser{s) on the terms and conditions stated in the above
instrument.
Purchase price
Paid [00,
0o