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HOME OF PELICAN ISLAND
Certificate No. 2098
CIIT 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:
Wasyl Ryszkanycz
(name)
914 Hawthorne Circle, Barefoot Bay, FL 32976
(address)
in and for consideration of the sum of $1.125.00 is entitled to full interment rights in
the Sebastian Municipal Cemetery for the following plot/niche:
Unit_ 4_ Block _18_ Lot_14_
of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and regulations
prescribed therefore by the City of Sebastian.
CONVEYED TIllS 11 th day of September, 2006.
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HOME Of PWCAN ISlAND
City of Sebastian Municipal Cemetery
Purchase Receipt
To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery
rate regulations, residence of purchaser or person for whom lot is intended for interment must be
provided at time of purchase
97(P
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Receipt is acknowledged in the sum of: I C()
f\ \j) _ n f\ 11 JI. ~ or ~--L r _ ) ~ .
l)!\UJ IvWu~ttvJ1l )NJ ft(>JAUUtorJ IIAWM.lL/~ 1" DOllars($/ J JS,OO )
on this ~day of ~ () f\{P}11 Vw l , ~ for the purchase of the following
described Cemetery Lot(S)~
Unit If , Block---LL, Lot(s) J L[ 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 - $20)
Opening & Closing l/5 I 00
e 0 H
Circle One
Vase and Ring for Niches (cost)
Interment
Disinterment
Signature of Purchaser
~. TOTAL$I~OO"DO
0J
. of Sebastian t
Service fees are to be paid at time of need only
I :\WW-DA T A \Ms-Cemetery\RECEIPT .doc
CITY OF SEBASTIAN
CITY CLERK'S OFFICE 3583
RECEIPT
{Vi Name W(lS~1 e!jSZkCLI1YCl- o Cash
Date q/lkO~ 0( Check # 83 I
No. Amount Paid
~ 001001 208001 Sales Tax
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C.\ 001501 322900 Garage Sales
~ 001501341920 CopiesIBid Specs.
001501 341910 LDC/Code of Ordinances
OJ 001501341930 Election Qualifying Fees
E j 125: lJD
i= 601010343800 Cemetery Lots
Lol/Niche J.L. Block /8 ,unit~
001501 343805 Cemetery Fees 15.~o
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In Loving Memory
Wasyl Ryszkanycz
Born
January 11, 1928
Poland
Died
September 17,2006
Barefoot Bay, Florida
Graveside Service
11:00 a.m., Wednesday
September 20, 2006
Sebastian Cemetery
Sebastian, Florida
Officiating
Dr. Ronald Thomas, Sr.
Pastor
Sebastian United Methodist Church
Sebastian, Florida
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FLORIDA DEPARTMENT OF
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
A.
1. Name of
Deceased
(TYPE)
First
Middle
Last
Date
of
Death
(If neither, give street address)
Month
Day
Year
Wasyl
Ryszkanycz
Sept.
17
2006
Barefoot Ba
Name of
Hosp. or
Inst.
2. Place of Death
County
Brevard
3. Name of Medical
Certifier Frederick Peterson, M.D
Medical Examiner Physician
4. Name of Funeral Home/DiralOt Qie/!e3'll't Address
Establishment
Strunk Funeral Home
5. Check a. D
Appropriate
Box
City, Town or Location
914 Hawthorne Circle
Address
Phone Number
6100 Minton Rd, 'lOll
Palm Ba , FL 32907
1623 N. Central Ave. Fla. Lic. NoJReg. No.
Sebastian, FL 1228
321-724-1172
Phone No. (Area Code)
772-589-1000
The medical certification has been completed and signed. A completed certificate of death accompanies this
application.
b. ~
Pam was contacted on 9/19/06
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. Peterson will complete and sign the medical
certification of cause of death within 72 hours.
c. D
was contacted on
He/she verified that
, Medical Examiner, will complete and sign the
6. Funeral Director/
Di~Ct Disposer
e of death within 72 hours.
F.E. NoJReg. No.
1862
Date Signed
9/18/06
B. BURIAL - TRANSIT PERMIT
} Permission is hereby granted to dispose of this body. Permit No. 1228-06-03611
It3 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 contacted by the funeral director and will not be able to complete the medical certification of cause-of-death section of the death certificate within
72 hours.
DNo extension of time for filing the death certificate has been requested.
F*giJtfaMlr Date Date Certificate
Subregistrar Signatur fY'...- Issued: 9/17/06 Dlje: 9/22/06
C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA
Ai:lproval Number:
Date
Medical Examiner, , gave authorization by telephone to
Funeral Director/Direct Disposer. Date
The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting period of 48 hours after death is
required for all cremations.
Method of Disposition:
~URIAL
DCREMATION
Signature of Sexton
or Perc;-:>n-in-Charge
CEMETERY OR CREMATORY
Sebastian
Place of Disposition
Cemetery
r; /~ olob
.
D.
DSTORAGE
Date of Disposition
DOTHER (Specify)
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This permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton) and returned
within 10 days to the local County Health Department in the county where disposition occurred.
DH 326, 8/97 (Obsoletes all previous editions)
(Stock Number: 5740-000-0326-2)
Distribution: White: Cemetery or Crematory
Yellow: Funeral Director or Direct Disposer
Pink: Local Registrar
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