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HOME OF PELICAN ISLAND
Certificate No. 2099
CIn( 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:
Lynne Griswold
(name)
1281 George Street, Sebastian, FL 32958
(address)
in and for consideration of the sum of $1.400.00 is entitled to full intennent rights in
the Sebastian Municipal Cemetery for the following plot/niche:
Unit_4_Block_09_Lot_09,10_
of the Sebastian Municipal Cemetery,
as maintained on t1le in the records of the City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and regulations
prescribed therefore by the City of Sebastian.
CONVEYED THIS 15th day of September, 2006.
BASTIAN, FLORIDA
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Name of Funeral HOQ'le
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Date of Mark-out
Date of Burial
Authorized by
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HOME OF PELICAN ISLAND
#: J097
City of Sebastian Municipal Cemetery
Purchase Receipt
To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery
rate regulations, residence of purchaser or person for whom lot is intended for intennent must be
provided at time of purchase
i . Jj
Name(s)
Address
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Receipt is acknowledged in the sum of:
OI\lQ ~~~, ~ tL'l-et ~'-----Dollars ($/400.00
. 'f-1l-
on this _I ~ day of
described Cemetery Lot(s) and or Niche(s).
Unit 1- ,Block-L, Lot(s) ~ ~ /0
)
, 20& for the purchase of the following
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 - $20) Opening & Closing ~ 75 I CO
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. ircle One
Vase and Ring for Niches (cost)
Interment
Disinterment
Signature of Purchaser
~ T:AL$/L/15.00
"Iy- f sebasti~
Service fees are to be paid at time of need only
I :\WW -DATA \Ms-Cemetery\RECEIPT .doc
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CITY OF SEBASTIAN
CITY CLERK'S OFFICE
RECEIPT
3585
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No.
001001 208001
001501 322900
001501 341920
001501 341910
001501 341930
601010343800
001501 343805
~
o Cash
~chJJ~9S'3 7fJ06
Amount Paid
Sales Tax
Garage Sales
Copies/Bid Specs.
LOC/Code of Ordinances
Election Qualifying Fees
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Cemetery Lots . sJI..l.:lL!iL
LotlNiche f.i.La, Block~ Unit~
Cemetery Fees
O/G
$ ,6-tiJ
<t II L '1 c:-Cc
TotalPaid ~
White - Dept. of Drigin. Yellow - Finance . Pink. Applicant
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FLORIDA DEPARTMENT OF
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
A. (TYPE)
1. Name of
Deceased
First
Middle
Last
Date
of
Death
(If neither, give street address)
Month
Day
Year
Stephen
F.
Griswold, Sr.
Sept.
9
2006
2. Place of Death
County
Brevard
City, Town or Location
Melbourne
Name of
Hosp. or
Inst.
Holmes Regional Medical Center
Phone Number
3. Name of Medical
Certifier John McKinney, Jr.., M.D.
Medical Examiner Physician
4. Name of Funeral Home/8;,&of. 9i81l88S1 Address
Establishment
Strunk Funeral Home
Address
1601 S. Apollo Blvd.
Melbourne, FL 32901
1623 N. Central Ave. Fla. Lic. NoJReg. No.
Sebastian, FL 1228
321-768-2816
Phone No. (Area Code)
772-589-1000
5. Check
Appropriate
Box
a.D
The medical certification has been completed and signed. A completed certificate of death accompanies this
application.
b. I!J
Lisa was contacted on 9/111 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. McKinney will complete and sign the medical
certification of cause of death within 72 hours.
c. 0
was contacted on
He/she verified that
, Medical Examiner, will complete and sign the
6. Funeral Director/
8irn\ '"'iilJ881il(
se of death within 72 hours.
"'.E. NoJReg. No.
1862
Date Signed
9/9/06
B.
BURIAL - TRANSIT PERMIT
1Permission is hereby granted to dispose of this body. Permit No. 1228-06-0353
[JJ 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.
R8!1iutr'iK.Qf
Subregistrar Signature
Date
Issued: 9/9/06
Date Certificate
Dlje: 9/14/06
C.
AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA
A~proval 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:
~BURIAL
CEMETERY OR CREMATORY
Place of Disposition Sebastian
D.
DSTORAGE
Date of Disposition
Cemetery
9/1<(lob'
DCREMATION
Signature of Sexton
or Per<;on-in-Charge
DOTHER (Specify)
} ,tr 9- ,,r; 1k?, "
T~is. 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
wlthm 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: lNhite: Cemetery or Crematory
Yellow: Funeral Director or Direct Disposer
Pink: Local Registrar
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