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HOME OF PELICAN ISLAND
Certificate No. 2062
CITY OF SEBASTIAN
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Dorothea Sanford
(name)
11 Sunset Drive, Sebastian, Fl 32958
(address)
in and for consideration of the sum of $700.00 is entitled to full interment rights in the
Sebastian Municipal Cemetery for the following plot/niche:
Unit 4_ Block 22_ Lot(s)Niche(s)_30_
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 26`x' day of January, 2006.
OF
rIAN, FLORIDA
Al Minner
ity Manager
W
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aio, MM
Clerk
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FLORIDA DEPARTMENT OF
HEALT
A.
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
1. Name of
First Middle Last
Date Month Day Year
Deceased
M Pandora Cerras
of
Death Jan. 21 2006
2. Place of Death
City, Town or Location
Name of (If neither, give street address)
County
Hosp. or
Indian River
Vero Beach
Inst. Palm Garden of Vero
3. Name of Medical
Certifier Gary
Silverman M.O.
Address
1265 36th Street
Phone Number
Medical Examiner Physician
Vero Beach, FL
772- 567 -6340
4. Name of Funeral Home /Direst- Dispesal» Address Fla. Lic. No. /Reg. No. Phone No. (Area Code)
Establishment
1623 N. Central Ave.
Strunk Funeral
Home Sebastian, FL 1 1228 772 -589 -1000
5. Check
a. ❑ The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate
application.
Box
b. [� Call was contacted on 1/23106
He /she verified that this death was from natural causes, that there as no accident nor other external cause of death,
and that Dr- Silverman 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
medi rtifi io use of death within 72 hours.
6. Funeral Director/
Si at , e l—' ' F.E. No. /Reg I!, No. Date Signed
E"rQCA SeF
1862 1/21/06
B.
BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228 -06 -0031
❑ 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 certificate has been requested.
R09WW-Qr--- �A Date Date Certificate
Subregistrar Signature (NIA, \ Issued: 1/21/06 Dye: 1/26/06
C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL- AT-SEA
M
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.
M od of Disposition:
BURIAL
❑CREMATION
Signature of Sexton
or Person -in- Charge
❑STORAGE
❑OTHER (Specify)
—Zee- Q-
CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemetery
Date of Disposition
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.
DH 326, 8197 (Obsoletes all previous editions) Distribution: White: Cemetery or Crematory
(Stock Number: 5740- 000 - 0326 -2) Yellow: Funeral Director or Direct Disposer
Pink: Local Registrar A-y-W %I Pdr-
MY Of
k`
HOME F PELICAN tJ ISL&ND
1225 Main Street, Sebastian, F132958
Telephone (772) 589 -5330 — Fax (772) 589 -5570
January 26, 2006
Dorothea Sanford
11 Sunset Drive
Sebastian, Fl 32958
Dear Ms. Sanford:
Enclosed is City of Sebastian Certificate 2062 entitling you to full interment rights in Cemetery
Lot 30, Blk 22, 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.
Si"y, _
Sally Ma'o, MMC
City Clerk
SAM:ar
enclosure
SIIIASTMN
HOME OF PELICAN ISLAND
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
Names)
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 ($ 72el. 4 6) )
on this day of , 20eG for the purchase of the following
described Cemetery Lot(s nd /or Nic s).
Unit , Block ,,�g_, Lot(s) 5;7-0 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 -$20) Opening & Closing A�% O H
Circle One
Vase and Ring for Niches (cost) Interment
Signature of Purchaser
of Sebastian
Disinterment
AL$ �Z7,5, 0�
Service fees are to be paid at time of need only
I: \W W- DATA \Ms- Cemetery\RECEI PT.doc
Name
Unit— Z/
S
Block
Lot- 5 0
Date of Mark-out
A
44
Date of Burial Time
Name of Funeral Home -,L/ 2
Authorized by—