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HOME OF PELICAN ISLA 4D
Certificate No. 2076
CITY OF SEBASMAN
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Herbert T. & Leone J. Thomas 701 Baird Avenue, Sebastian, Fl 32958
(name) (address)
in and for consideration of the sum of $1,400.00 is entitled to full interment rights in
the Sebastian Municipal Cemetery for the following plot/niche:
Unit 4_ Block _18_ Lot(s)Niche(s)_6 & 7_
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 27th day of March 2006.
OF BASTIAN, FLORIDA ATTEST- ,'!
Al Minner Sal Maio, MMC
City Manager City Clerk
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Name e,
Unit
Lot I-
Date of Mark-out
Date of Burial ( A Time
Name of Funeral Homa,
Authorized by
B BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 08 °2617 -156
EJA 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 d ath cert' to as been requested.
Date Date Certificate
Registrar or 8/15/08 8/25/08
Subregistrar Signature Issued: Due:
C.
TION 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.
D CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition S G B�4 S A*/
94RIAL STORAGE Date of Disposition g l;2/ 1O 8 -
OCREMATION OTHER (Specify)
Signature of Sexton
or Person -in- Charge
This permit must be endorsed by the Sexton or person -in- charge (or by the Funeral Director/Direct Disposer when there Is no aexion) arru rCkui I Gil
within 10 days to the local County Health Department in the county where disposition occurred.
Distribution: white: Cemetery or Crematory
DH 326, 6/47 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer Pink focal Registrar xm� %I pdpff
(Stock Number: 57404000 -0326 -2)
FIARIDA DEPARTMENT OF
State of Florida, Department of Health, Vital Statistics
HEALT
APPLICATION FOR BURIAL - TRANSIT PERMIT
A. (TYPE)
1. Name of
First Middle Last Date Month Day Year
of
Deceased
HERBERT H. THOMAS Death 8 /14/08
2. Place of Death
City, Town or Location
Name of (If neither, give street address)
County
INDIAN RIVER
VERO BEACH
Hosp. or
Inst. ALTERRA STERLING HOUSE
3. Name of Medical
Address
Phone Number
GARY R.
SILVERMAN, MD
1265 36TH ST
Certifier
VERO BEACH, FL 32960
772° 5676340
Medical
Examiner Physician
4. Name of Funeral Home /Direct Disposal
Address
Fla. Lic. No./ g. No.
one No. (Area Code)
735 FLEMING ST
Establishment
SEAWINDS FUNERAL HOME
SEBASTIAN, FL 32958
2617
772- 589 -1933
5. Check
a. The medical certification 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,
will complete and sign the medical
and that
certification of cause of death within 72 hours.
was contacted on He /she verified that
C. �
, Medical Examiner, will complete and sign the
medical certifi n of cause of de in 72 hours.
6. Funeral Director/
Si a F.E. No. /Reg. No. Date Signed
FO 44126 8/15/08
Direct Disposer
B BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 08 °2617 -156
EJA 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 d ath cert' to as been requested.
Date Date Certificate
Registrar or 8/15/08 8/25/08
Subregistrar Signature Issued: Due:
C.
TION 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.
D CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition S G B�4 S A*/
94RIAL STORAGE Date of Disposition g l;2/ 1O 8 -
OCREMATION OTHER (Specify)
Signature of Sexton
or Person -in- Charge
This permit must be endorsed by the Sexton or person -in- charge (or by the Funeral Director/Direct Disposer when there Is no aexion) arru rCkui I Gil
within 10 days to the local County Health Department in the county where disposition occurred.
Distribution: white: Cemetery or Crematory
DH 326, 6/47 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer Pink focal Registrar xm� %I pdpff
(Stock Number: 57404000 -0326 -2)
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
c p AMIN ST
HOME CIF PELICAN L"D
For information contact:
Kip Kelso - Cemetery Sexton
Sebastian Municipal Cemetery
(772) 589 -2545
City Clerk's Office
City Hall, 1225 Main Street
Sebastian, FL 32958
Office (772) 388 -8215 or 388 -8214
Fax: (772) 589 -5570
FUNERAL HOME: �erf� +J I N
ADDRESS: 73 11- l k
PHONE #: 17 - G99- 19
(Chec ne)
OPEN BURIAL LOT Lot (o Block
OPEN CREMAINS LOT Lot Block
OPEN COLUMBARIUM NICHE Niche Block
N S
BURIAL DATE AND SERVICE TIME:
FOR DECEASED: T )EK.W6zr -7k O M 60 S
Name
Unit
Unit
Unit
E W
3Z
NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE:
(Must provide proper documentation of ownership)
Name ignature Date
I certify that I have determined the ownership of the above described site, that all site fees and
administrative fees have been paid and authorize opening of same.
NAME AND SIGNATURE OF LICENSED FUNERAL DIRECTOR:
Name S' nature Date
Cemetery Sexton Certification:
I certify that I have checked the ownership information by viewing the owner's deed and confirming
with Clerk's office and that all fees have been paid:
$ o
Cem e Sexton Date
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.
MY Of
HOME OF PELICAN 951AN D
1225 Main Street, Sebastian, Fl 32958
Telephone (772) 589 -5330 – Fax (772) 589 -5570
March 27, 2006
Herbert T. Thomas
701 Baird Avenue
Sebastian, Fl 32958
Dear Mr. Thomas:
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Enclosed is City of Sebastian Certificate 2076 entitling you to full interment rights in Cemetery
Lots 6 & 7, 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.
Sin
c ly,
Sally M ' ,'MMC
City Clerk
SAM:ar
enclosure
,yY 7y f V1l +St'
"MT, OF 7WCAN 7�7WM
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
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:
Dollars
on this `" day of %�� , 2Q�C for the purchase of the following
described Cemetery Lot(s) and /or Niche(s).
Unit _ , Block /c? , Lot(s) L ;-�j'/ Niches
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) Interment
Signature of Purchaser
of
7� e"�"5
Disintermen
(:l4V O H
Circle One
TOTAL $
D
Service fees are to be paid at time of need only
I: \W W- DATA \Ms - Cemetery\RECEI PT.doc
a Wl�ipS;FUPIERA<: �{pp�E VERQ BEACH, FL 32963
SUNrRUST BANK 5726
�Ok §TAtET
63- 607/670
4 8,EACK FL 32960 ,
3/24/2006
City of Sebastian I $ **1,475.00
One Thousand Four Hun(
s City of Sebastian
1225 Main St.
Sebastian, FL 32958
Thomas
11000 5 7 2 611'
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my -Five and 00/ 100**** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** *DOLLARS
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