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Certificate No. 2079
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Janet M. Galka
(name)
1118 Tequesta Dr., Barefoot Bay, Fl 32976
(address)
in and for consideration of the sum of $1,125.00 is entitled to full interment rights in
the Sebastian Municipal Cemetery for the following plot/niche:
Unit 4_ Block _18_ Lot(s)Niche(s)_18_
of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and regulations
prescribed therefore by the City of Sebastian.
CONVEYED THIS 28th day of Apri12006.
)RIDA AT `I':
?~;
r"rt 6/ i/ G' '"' Yp
SaI,Y Maio, MMC
./'City Clerk
~TI1' C}1'
Kra
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'u p~1~3~ '6/~F C U:~l~~ 13.~S.F~l~lwv
1225 Main Street, Sebastian, Fl 32958
Telephone (772) 589-5330 -Fax (772) 589-5570
Apri130, 2006
Ms. Janet M. Galka
1118 Tequesta Drive
Barefoot Bay, Fl 32976
Dear Ms. Galka:
Enclosed is City of Sebastian Certificate 2079 entitling you to full interment rights in Cemetery
Lot 18, Block 18, Unit 4. Also enclosed is a copy of the receipt and the Rules and Regulations
governing the Sebastian Municipal Cemetery.
If you have any questions, please contact our office.
Sinc rel
,.
Sally M ' , MMC
City Clerk
SAM:ar
enclosure
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HOME OF PEUGN ISUUVp
City of Sebastian Municipal Cemetery
Purchase Receipt
To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery
rate regulations, residence of purchaser or person for whom lot is intended for interment must be
provided at time of purchase
~~
-~ A N
Name(s)
~( 3297
Address U i
~ 72 - x(03- l3z7
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Receipt is acknowledged in the sum of:
~ lnu~4 R~~l ~rW~fy ~~ Jt Dollars ($ I ! 2 S. a~ )
on this ~-~ day of ~~~ ~ , 20 ~~ for the purchase of the following
described Cemetery Lot(s) and/or Niche(s).
Unit ~ ,Block 1 P~ , Lot(s)~~ Niche{s)
r .~. .
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
Vase and Ring for Niches (cost)
ignatu a of Purchaser
W O H
Circle One
Interment Disinterment
'~~~
,;' ;
~ity of Seba ian
Service fees are to be paid at time of need only
I:\W W-DATA1Ms-CemeterylRECEtPT.doc
OX-GIFFORD-SEAWINDS FUNERAL HOME
1950 20TH STREET
VERO BEACH, FL 32960
PAY TO THE
ORDER OF .
SUNTRUST BANK
VERO BEACH, FL 32963
63-607/670
DOLLARS 8
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Date of Burial ~ ~ ~`~ ~ ~ Time ~ .~ p t3 At ~ ~ ~l ~ ~ ~
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COX-GIFFORD-SEAWINDS FUNERAL HOME, suNrRUSr eariK H917
1950 20TH STREET VERO BEACH, FL 32960
VERO BEACH, FL 32960 63-215/631
.2/6/2007
PAV To THE.. City of Sebastian ~ $ **75.00
ORDER OF
Seventy-Five and 00/100**************************************************************
DOLLARS
City of Sebastian
1225 Main St.
Sebastian, FL 32958
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FLORIDA DEPARTMENT OF
HEALT
A. (TYPE)
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL -TRANSIT PERMIT
1. Name of First Middle Last Date Month Day Year
Deceased of
,. BERTHA PIATOWSKI Death 1/28/07
2.. Place
of Death City, Town or Location Name of (If neither, give street address)
ty
I
DI por
N
AN RIVER VERO BEACH ~st ATLANITIC HEALTHCARE CENTER
3. Name of Medit;ar Address Phone Number
Certifier GARY RL. SILVERMAN, , 1265 36TH ST
Medical Examiner Physician VERO B~'iACH, FL 3296- 772-567-6340
4. Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment 735 FLEMING ST
SEAWINDS FUNERAL HOME SEBASTIAN FL 32958 2617 772-589-1933
a. t;neac a. U me medical certircation has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b.
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
certfication of cause of death within 72 hours.
c. ~ was contacted on He/she verified that
Medical Examiner, will complete and sign the
medical ification of cause of de in 72 hours.
6. Funeral Director/ ignature F.E. No./Reg. No. Date Signed
Direct Disposer ~ 2294 1 / 30 / 07
B.
BURIAL -TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 07-2617-026
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.
~No extension of time for filing the death certifi to has been requested.
Registrar or Date 1/ 3 0/ 0 7 Date Cert~ X 5/ 0 7
Subregistrar Signature Issued: Due:
~~ ~~ ! i
c. AUTHORIZATION for CREM~4TION, DISSECTION, or BURIAL-AT-SEA
Approval Number: Date
Medical Examiner, ,gave authorization by telephone to
Funeral Diredor/Direct Disposer. Date
The Medical Examiner's approval must be obtained before disposal by any of the above methods. Awaiting period of 48 hours after death is
required for all cremations.
D. CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition ~,~~,¢ ~ i ~ r ~,C ~j,~ ,~
BURIAL STORAGE Date of Disposition a./ / ~D
-~
CREMATION OTHER (Specify)
Signature of Sexton ~ ~ _ /~
or Person-in-Charge .~o_i`/•c%,~, -
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.
Distribution: White: Cemetery or Crematory
DH 326, BIg7 (Obaoletes ell previoua editions) Yellow: Funeral Director or Direct Disposer ~ `~ ~
(Stock Number. 5740-000-0326-2) Pik Local Registrar