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HOME OF PELICAN ISLAND
Certificate No. 2144
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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:
Lily McCombs and/or Gregg McCombs 156 Day Drive, Sebastian, FI 32958
(name) (address)
In and for consideration of the sum of $1,400.00 is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following
Lot(s)/Niche(s)
Unit_4_Block_10_Lot(s)_3 & 4_
of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and
regulations prescribed therefore by the City of Sebastian.
CONVEYED THIS 25th day of July, 2007.
CITY OF S AST , FL,~JRIDA ATTbST:
n er Sally .Maio, MMC
City an ger City Clerk
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125 ~lair~ Street, S~b~~~i~r~, I^~ ~?~~~'
)uly 25, 2007
Lily McCombs and/or Gregg McCombs
156 Day Drive
Sebastian, F1 32958
RE.• Interment Rights to Unit 4, B/ock 10, Lots 3 & 4 Sebastian Cemetery
Dear Mrs. McCombs:
Enclosed is City of Sebastian Certificate 2144 entitling you to full interment rights in
Unit 4, Block 10, Lots 3 & 4.
Also enclosed is a copy of the Rules and Regulations governing the Sebastian Municipal
Cemetery.
If you have any questions, please contact our office.
Sin ely,
,-
' ''
Sally A. aio, MMC
City Clerk
SAM:ar
enclosures
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Date of Burial. ,- _ t_ . ~ _ Time ~, ~~ "
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City of Sebastian Municipal Cemetery
Purchase Receipt
Area Code & Phone Number
gl~
Residence Address of Intended Occupant if Other Than Purchaser
Ofifice Use Only
Receipt is acknowledged in the sum of:
Dollars ($ ~'7" Q~, DO )
on this day of , 20~ for the purchase of the following
describe Cemetery Lots d/o fiche(s).
Unit , Block ~, Lot(s)_,;~~_7`_ 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 025 .~ ~ W O H.
Circle One
Vase and Ring for Niches (cost) Interment Disinterment
TOTAL $ I Sa.S. OO
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Si natu of Purchaser ty of Sebastian
Service fees are to be paid at time of need only
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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
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CHARLES J. McCOMBS
LILY M. McCOMBS
156 DAY DRIVE
SEBASTIAN, FL 32958
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63-1383/670 2 ~ O L'
01097679
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1020 U.S. Hwy 1
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i B6GB93.g4Fbride 32956 , ~ ~~ ~
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FIARIDA DEPARTMENT OF ~ O
HEALT State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL -TRANSIT PERMIT
A• (TYPE)
1. Name of First Middle Last Date Month Day Year
Deceased of
CHARLES J. MCCOMBS Death 7/24/07
2. PPlace of Death City, Town or Location Name of (If neither, give street address)
II~Dn~AN RIVER SEBASTIAN Hosp. or 156 DAY DRIVE
Inst.
3. Name of Medical CURTIS DALILI, MD Address1715 37TH PLACE Phone Number
Certfier
Medical Examiner X Physician VERO BEACH, FL 32960 772-794-2272
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
5. Check a. ® The medical certfication 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.
a ~ was contacted on
He/she verified that
Medical Examiner, will complete and sign the
medical ce ' tion of cause of death within 72 hours.
6. Funeral Director/ afore F.E. No./Reg. No. Date Signed
Direct Disooser ,~ 2 2 9 4 7/ 25 / 0 7
B. "' ~ BURIAL -TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 07-2617-138
®A five (5) day extension of time for filing the death certificate (exGusive 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 certfication of cause-of-death section of the death certficate within
72 hours.
~No extension of time for filing the death rtfica rhas requested.
Registrar or ~ /` Date Date Certificate
SubregistrarSignature ((( { Issued. 7/25/07 Due. a/1/07
c. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA
Approval Number:
Date
Medical Examiner, ,gave authorization by telephone to
Funeral DirectodDirect Disposer. Date
The Medical Examiners 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 SEBASTIAN CEMETERY
BURIAL
CREMATION
Signature of Sexton
or Person-in-Charge
STORAGE
l OTHER (Specify)
J -~ ,.~
Date of Disposition 7 / 28 / 0 7
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.
Distritwtion: tnmite: cemetery or Crematory
DH 326, Bf97 (Obsoletes all previous editions) Yelkriv: Funeral DireGOr or Direct Disposer
(Stock Number. 5740-000-0326.2) Pink: Local Registrar ~}y `~ ,~