HomeMy WebLinkAbout4-17-15EG
- V
i
Name.
Unit—
Block t —
Lot
Date of Mark -out Q r t r^ O
Date of Burial
f/y /a 57 Time—//
Name of Funeral H e 77V
Authorized by
FLORIDA DEPARTMENT OF
HEALT
A. (TYPE)
State of Florida, Department of Health, Vital Statistics PY
APPLICATION FOR BURIAL - TRANSIT PERMIT CO
1. Name of First
Middle
Last
Date Month Day Year
Deceased Nancy
L.
Wood
Oct. 9 2005
Death
2. Place of Death City, Town or Location
Name of
(If neither, give street address)
County
Hosp. or
Indian River
Sebastian
Inst.
Sebastian River Medical Center
3. Name of Medical
Address
Phone Number
Certifier Nasir Rizw't, M.D
13885 U.S.
#1
Medical Examiner FfiPhysician
Sebastian,
FL
772 -589 -6844
4. Name of Funeral Home/Dl et*DI8�
Address
Fla. Lic. NoJReg. No.
Phone No. (Area Code)
Establishment
1623
N. Central Ave.
Strunk Funeral Home
Sebastian, FL
1228
772- 589 -1000
5. Check a.
Appropriate
Box
b.
C. F1
The medical certification has been completed and signed. A completed certificate of death accompanies this
application.
Jan was contacted on 10110/05
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. RIzwi will complete and sign the medical
certification of cause of death within 72 hours.
was contacted on He/she verified that
Medical Examiner, will complete and sign the
of death within 72 hours.
6. Funeral Director/ S' t F.E. NodReg. No. Date Signed
WF pp ,, _ 1862 1019105
B.
BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No.: 1228-05-0419
E] 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.
fleglsharwr —• Date
Subregistrar Signature Issued: 10/9105
C.
Approval Number.
Medical Examiner,
11
v
Date Certificate
Dye; 10/14/05
AUTHORIZATION for CREMATION, DISSECTION, or BURIAL- AT-SEA
Date
gave authorization by telephone to
Funeral Director /Direct Disposer. Date
The Medical Examiners 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.
Method of Disposition:
dBLIR-IAL
OCREMATION
Signature of Sexton
or Person-in-Charge
DSTORAGE
OTHER (Specify)
) .
This permit must be endorsed by the Sex
within 10 days to the local County Health
CEMETERY OR CREMATORY .
Place of Disposition Sebastian Cemetery
Date of Disposition p S
or person -in- charge (or by the Funeral Director /Direct Disposer when there is no Sexton) and returnea
)artment in the county where disposition occurred.
Distribution: White: Cemetery or Crematory
DH 328, 8197 (Obsoletea all prevbw editions) Yellow Funeral Director a 0DZW Disposer
(Stock Number. 5740 000-0328 2) PiNc local RsglsVar ,,�,� i� ,y.
Total Pald$�y
Initi Is
White — Dept. of Origin a Yellow — Finance • Pink • Applicant
CITY OF SEBASTIAN
CITY CLERK'S OFFICE
RECEIPT
Name
0 Cash
0
#�
Date
XCheck
No.
Amount Paid
001001208001
Sales Tax
001501322900
Garage Sales
001501341920
CopieslBid Specs.
001501341910
LDC1Code of Ordinances
001501341930
Election Qualifying Fees
601010 343800
Cemetery Lots j
--
(�--
LotlNiche 5' I Block J'7 Unit
001501 343805
Cemetery Fees
Total Pald$�y
Initi Is
White — Dept. of Origin a Yellow — Finance • Pink • Applicant
NPA
Qly or
SJDAST IY i�GS
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
pjgvided at time of purchase
Na. 7)
Address
Area Code & Phone Number
MOM
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Receipt is acknowledged in the sum of:
p a�
Dollars ($
on this day of 2045 for the purchase of the following
described Cemetery Lot(s) and /or Niche(s).
Unit , Block , Lot(s) / s �/h 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 (w_) O H
Circle One
Vase and Ring for Niches (cost) Interment Disinterment
Signature of Purchaser
ity of Sebastian
T $
Service fees are to be paid at time of need only
I: \W W- DATA \Ms- Cemetsry\RECEI PT.doc
1225 Main Street, Sebastian, F132958
Telephone (772) 589 -5330 —Fax (772) 589 -5570
October 27, 2005
James W. Wood
778 Gossamer Wing Way
Sebastian, Fl 32958
Dear Mr. Wood:
Enclosed is City of Sebastian Certificate 2050 entitling you to full interment rights in Cemetery
Lots 15 & 16, Block 17, 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.
S' cerely,
Cme
cktl-
1 Sally Mai MMC
City Clerk
SAM:ar
enclosure