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Certificate No. 2076
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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 A
Al Minner
ity Manager
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JJf Maio, MMC
City Clerk
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FLORIDA DEPARTMENT OF
HEALT StaAPPLICATION FOR BURIAL HTaRAN IT PERM Ttcs
A. (TYPE)
1. Name of First Middle Last Date Month Day Year
Deceased LEONE J . THOMAS °f MARCH 22 , 2006
Death
2. Place of Death City, Town or Location Name of (If neither, give street address)
County INDIAN RIVER VERO BEACH Hosp. or INDIAN RIVER MEMORIAL HOSPITAL
Inst.
3. Name of Medical Address Phone Number
Certifier JANET E. ANDERSON, M.D. 372 17TH STREET
Medical Examiner X Physician VERO BEACH, FLORIDA 32960 772-794-7791
4. Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment 735 FLEMING STREET 2617 772-589-1933
SEAWINDS FUNERAL HOME SEBASTIAN, FLORIDA 32958
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,
and that will complete- and sign the medical
certification of cause of death within 72 hours.
c. ~ was contacted on He/she verified that
Medical Examiner, will complete and sign the
medic~icertification of cause of death within 72 hours.
6. Funeral Girector/ Signat 're F.E. No./Reg. No. Date Signed
Direct Cisposer ~~ 2294 MARCH 23, 2006
B. BURIAL -TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 06-2617-062
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 rtif to has been requested.
Registrar or Date Date Certificate
SubregistrarSignature Issued: MARCH 23, 2006 Dye: MARCH 28, 2006
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. Awaiting period of 48 hours after death is
required for all cremations.
D. CEMETERY OR CREMATOR`I(
Method of Disposition: Place of Disposition SEBASTIAN CEMETERY
®BURIALSTORAGE Date of Disposition MARCH 27, 2006
CREMATION
Signature of Sexton
or Person-in-Charge
^OTHER (Specify)
This permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Director/Dirdct 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, 8/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number. 5740-000-0326-2) Pink: Local Registrar
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Date of Burial
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