HomeMy WebLinkAbout4-09-11
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HOME OF PELICAN ISLAND
Certificate No. 2103
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:
Truman Jones
(name)
308 Concha Drive, Sebastian, FL 32958
(address)
in and for consideration of the sum of $700.00 is entitled to full interment rights in the
Sebastian Municipal Cemetery for the following plot:
Unit 4
Block 9
Lot 11
- -
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 29th day of September, 2006.
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HOME Of I'WCAN ISI.AND
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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 purcbase '
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36 % Co (l c.J\a.:D \'l0 e. $e h:;) s-f I a f\
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Name(s)
Address
3d I - 5'-1- 4-' 3'g I d- - Cell i)hOl)€_
Area Code & Phone Number '
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
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5/f-)cft ;m:a:i!)
Dollars ($ ~ 25 a!. )
ir>N
, 20 0& for the purchase of the following
on this ~q"'" day of /uA....
described Cemetery Lot{s) and/or Niche{s).
Unit 1- , Block 9 I Lot(s) 1/
Niche(s)
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for use in accordance with the conditions, ordinances, resolutions, rules and regulations
presctlbed therefore by the City of Sebastian.
Additional Fees paid at time of purchase: (
Comer Markers (set of 4 - $20) Opening & Closing :It / 2 ~j~-
~~/t6
w~ H
ne
Vase and Ring for Niches (cost)
Interment
Disinterment
'c:' -
, / " (t1.A)u.d.d )
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Signature of Purc \ a~r t .
( _ TOTAL $
'--- /1J f< . )1J
citY of S astian
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6' L,..-.) .-
Service fees are to be paid at time of need only
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Name
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Unit
Block
Lot I (
Date of Mark-out
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Time
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Date of Burial
Name of Funeral Hom .
Authorized by
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
NANCY
ANN
JONES
SEPTEMBER 24, 2006
2. Place of Death
County
BREVARD
City, Town or Location
Name of
Hosp, or
lnst.
4 N. CARVER DRIVE
CAPE CANAVERAL
3. Name of Medical
Certifier SAJID S. QAISER, M.D.
Address
Phone Number
Medical Examiner Physician
4. Name of Funeral Home/Direct Disposal Address
Establishment 735 FLEMING STREET
SEAWINDS FUNERAL HOME SEBASTIAN, FLORIDA 32958
5, Check a. IKJ The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
1750 CEDAR STREET
ROCKLEDGE, FLORIDA 32955
Fla. Lie. No.lReg. No,
321-633-1981
Phone No. (Area Code)
2617
772-589-1933
b. D
was contacted on
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that 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/
Direct Disposer
medical certification of cause of death within 72 hours.
F.E. No.lReg. No.
Date Signed
-~6
B.
BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 06-2617 -157
o 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.
ONo extension of time for filing the death cert'ficat
Registrar or
Subregistrar Signature
Date
Issued:
09/28/06
Date Certificate
Dlle: 10/04/06
C,
AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT -SEA
Approval 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:
CEMETERY OR CREMATORY
Place of Disposition
D.
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.
IKlBURIAL
DCREMATION
Signature of Sexton
or Perc;':m-in-Charge
o STORAGE
Date of Disposition
SEBASTIAN CEMETERY
f/3o~6,
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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 ~egistrar
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