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Home My WebLink About4-10-39CITY OF HOME OF PELICAN ISLAND Certificate No. 2157 ~~ O~ ~~ ~~ Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: John 8~/or Leola Gnacinski 475 Watercrest Street, Sebastian, FL 32958 (name) (address) In and for consideration of the sum of $2,000.00 is entitled to full interment rights in the Sebastian Municipal Cemetery for the following lots: Unit_4_Block_10_Lots_38 & 39_ 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 6th day of December, 2007. EBASTIAN, FLORIDA ATTE : ? ~AI Minner ity Manager Sally A.,~i~laio, MMC ~tv Clerk „ ~',~1 ~"~~T' /~ C- / t~ ~ .~ / ', -~ ,"'alt' S Name `'~ ~"~` ~` Unit / Block f r~ Lot ~ ~~ Date of Mark-out ~ ~ ! '~ ~~ ~~ r.~ ~.~.. Date of Burial / ~ % ~ ~ Time ~ ,__ Name of Funeral Home ~, ~~^ ~ ~~ ~ f~ ~~ ~ Authorized by L-~-_..}t -'~~.,t•~4 ~,;~~~t~~,G~-~~, ~ N sEeasrlaN John Gnacinski John J. "Jack" Gnacin- ski, 69, died May 15, 2009, CITY OF SEBASTIAN at Indian River Medical CffY CLERK'S OFFICE 4 5 5 Center, Vero Beach. RECEIPT He was born in Erie, Pa., and lived in /r ~ x ~ '- c (' _ ,y '" ~ Sebastian Ci~ T ~G1 Name L- ^ Cash ~ since 1995, ~~~ //;; /~ ~ ~~ ~ `7 " ~`7 D t 7 Check p ~ 7 l ~ ~~,~ ; :~ coming from a e ~- his birth- place. No• Amount Paid He was re- tired from 001001208001 Sales Tax Hammermill Paper Co. 001501322900 Garage Sales He was former member of Sebastian Golf Course. 001501341920 CopieslBid Spec. Survivors include his wife of 35 years, Leola; 001501341910 LDC/Code of Ordinances sons, Mark Gnacinski and David Gnacinski, both of 001501 341930 Ek~ction Qualifying Fees Erie, Timothy King of G h ~ 1 n 5 K.I L Barefoot Bay and Brian ots 601010 343800 Cemetery King of Erie; daughters, LoUNiche ~_, Bkx* ~ U , Unft Rebecca Jennings of Micco ~-- 5 and Valerie King of Erie; 001501 343805 Cemetery Fees ~ and several grandchildren. He was preceded in death by a son, John; brother, Raymond Nason; and sister, Dorothy Wochner. SERVICES: Visitation will be from 1 to 2 p.m. May 18 at Seawinds Funer- al Home, Sebastian, with a funeral service at 2 p.m. Monday. Burial will follow in Sebastian Cemetery: A /,~ v ~ ~ ~ 0 ~ ~ guest book may besigned l/ Total Paid P . at seawindsfh.cam/ Initials Oblt.php. ~.•w~ .~~~nnc White - Dapt. of Origin • Yellow -Finance • Pink • Applicant FLORIDA DEPARTMENT OF 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 JOHN J , GNACINSKI °f 05 15 2009 Death 2. Place of Death City, Town or Location Name of (If neither, give street address) County INDIAN RIVER VERO BEACH Hosp. or Inst. INDIAN RIVER MEDICAL CENTER 3. Name of Medical Address Phone Number Certifier RICHARD PENLY, MD 1265 36TH STREET Medical Examiner X Physician VERO BEACH, FL 32960 772-567-6340 4. Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No. (Area Code) Establishment 735 S FLEMING ST 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 ~ DR. PENLY was contacted on 05/ 16/09 He/she verified that this death was from natural causes, that there was no accident nor other external cause of death, and that HE 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 romplete and sign the medical certification of cause of death within 72 hours. 6. Funeral virector/ Si star F.E. No./Reg. No. Date Signed FO 44126 05/18/09 Direct Disposer B. BURIAL -TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No. 09-2617-113 ®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 t 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 th cert~ i to s been requ sted. Registrar or Date Date Certificate SubregistrarSignature Issued: 05/18/09 Dye: 05/29/09 ~. 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. Method of Disposition: ®BURIAL CREMATION Signature of Sexton or Person-in-Charge STORAGE OTHER (Specify) __~~ CEMETERY OR CREMATORY Place of Disposition SEBASTIAN CEMETERY Date of Disposition 05/18/09 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 Wnite Cemetery or Crematory Yepnw. Funeral Director or Direct Disposer ~p UH 326, 8/97 !Obsoletes all previous editions) Pink. Local Registrar x~.,,~r.e i~• ~.eo.. (Stock Number. 5740-000-0326-2) i~ FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY ~a . SEAN For information contact: Kip Kelso -Cemetery Sexton Sebastian Municipal Cemetery {772) 589-2545 City Clerk's Office City Hatl, 1225 Main Street -Sebastian, F~ 32958 Offrce (772} 388-8215 or 388-8214 Fax: {772) 589-557Q FUNERAL HOME: °S~,~-AyyU1~~~S ADDRESS: ~-3~ I'!£/Y)~n/Gi' ..~r ~~.5?1f~, F~ PHONE #: 77~- S (Check One) ~/ OPEN BURIAL LOT OPEN CREMAINS LOT OPEN COLUMBARIUM NICNE BURIAL DATE AND SERVICE TIME: Lot 3 `ti Block 1 O _ ____ Unit Lot Block Unit Niche Block Unit N S E W 2', 00 ~ ~f~n9 FOR DECEASED: ~o In n) In N ~k G ~ S ~ I Name NAME AND SIGNATURE OF LOl` OWNER OR REPRESENTATIVE: {Must provide proper documentation of ownership} , .l~'OIPr ~iVA Ci~l.S~~ Q~,ae~ f-~' s~,~- o ~ Name Signature Date 1 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 SIrGN-ATURE OF LICENSED FUNERAL RECTOR: Name ~ S' at re Date Cemetery Sexton Certification: I certify that !have checked the ownership information by viewing the owner's deed and confirming with C{ark's office a t tall #ees have been paid: ~.-- ~ Cem ery S xton Dat . This form to be provided to Clerlk's Office by Sexton for permanent record upon completion.