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C17YOF
SEA
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HOME OF PELICAN ISLAND
Certificate No. 2023
ITY 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:
Dennis Taylor 8536102nd Avenue, Vero Beach, Fl 32967
(name) (address)
in and for consideration of the sum of $950.00 has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plot:
Unit-4— Block _17_ Lots _17_
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 16th day of June, 2005.
CITY
FLORIDA
(, ivll '
Sally A. aio, MMC
tv Clerk
N
•� 0
Name
Unit
Block
Lot
Date of Mark-out
Date of Burial
Name of Funeral Home
Authorized by
?
Time
A.
FLORIDA DEPARTMENT OF
HEALT
(TYPE)
State of Florida, Department of Health, Vital Statistics C(DF)y
APPLICATION FOR BURIAL - TRANSIT PERMIT
1. Name of First Middle
Last
Date Month Day Year
Deceased
of
Kjersten Elizabeth
Pearson
Death June 3 2005
2. Place of Death City, Town or Location
Name of (If neither, give street address)
County
Hosp. or
Indian River Vero Beach
Inst. Indian River Memorial Hospital
3. Name of Medical
Address
Phone Number
Certifier Richard Cunnin ham, D. Q.
901 37th
Street
Medical Examiner Physician
Vero Beach, FL
772 -978 -5600
4. Name of Funeral Home /Dimet 909pesel +
Address
Fla. Lic. No. /Reg. No.
Phone No. (Area Code)
Establishment
1623 N. Central Ave.
Strunk Funeral Home
Sebastian, FL
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. Dr. Cunningham was contacted on 6/5/05
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 complete and sign the
medical cedyrcati n up,of death within 72 hours.
6. Funeral Director/ na a F.E. No. /Reg. No. Date Signed
Direct Disposer 1862 6/10/05
B. BURIAL - TRANSIT PERMIT
C.
Permission is hereby granted to dispose of this body. Permit No. 1228-05-0259
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.
RNo extension of time for filing the death certificate has been requested.
Rgg�f r Date Date Certificate
Subregistrar Signature Issued: 6/10/05 Dye: 6/15/05
Approval Number:
AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA
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.
D. CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition Sebastian Cemetery
BURIAL
CREMATION
Signature of Sexton 1
o . Person -in- Charge
STORAGE
OTHER (Specify)
Date of Disposition tr-
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: White: Cemetery or Crematory
DH 326, 8197 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number: 5740 -000- 0326 -2) Pink: Local Registrar XIWI -r C. P,oe
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SEISASTIM o
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
me(s)
o =Z .3.296 d
Address ?5�6 /,a ,,.,r2 • J.496 7
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Receipt is acknowledged in the sum of:
Dollars (V, cV- o d )
on this /6.t,"G day of , 20 os'for the purchase of the following
described Cemetery Lot( nd/or Niche(s).
Unit_, Block 17 , Lot(s) 117 Niches)
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 - $20) Opening & Closing %S� d O H
Circle One
Vase and Ring for Niches (cost) Interment Disinterment
Signature of Purchaser
r" x v
of Sebastian
TOT—AL—$—/,O R-.51 d d
Service fees are to be paid at time of need only
I: \W W- DATA \Ms - Cemetery\RECEIPT.doc
KJersten Pearson,
Vero Beach
Kjersten Elizabeth Pear-
son, 52, died June 3, 2005, at
Indian River Memorial Hos-
pital, Vero Beach.
She was born in Clinton,
Iowa, and moved to Vero
Beach in 1992, coming from
Lake Worth.
She was a graphic artist.
She was a graduate of Au-
gustana College in Rock Is-
land, Ill.
She attended First Presby-
terian Church and Christ the
King Lutheran Church, both
of Sebastian.
She was the owner of Mad -
hatter Printers in Lake Park,
and worked as a graphic art-
ist for the Sebastian Sun and
'the Florida Directory in Se-
bastian: She worked in the
Photo lab at the Sebastian
Wal -Mart.
She was an accomplished
musician and was a'percus-
sionist. .
Survivors include her hus-
band'of 11 %a years, Dennis
Taylor; and brother, Paul
Pearson of Bethel, Conn.
Memorial contributions
may be made to the Humane
Society of Vero Beach, P.O.
Box 644, Vero Beach,: FL
32961.
SERVICES: Visitation will
be from 1 to 2 p.m. June 15,
at the Strunk Funeral Home,
Sebastian. A service will fol-
low at 2 p.m. in the funeral
home chapel-with the Rev.
Julia Shreve officiating.
Burial will follow -in Sebas-
tian Cemetery; Sebastian.
awOF C(DPY
SE HOME OF PELICAN ISLAND
1225 Main Street, Sebastian, Fl 32958
Telephone (772) 589 -5330 — Fax (772) 589 -5570
July 5, 2005
Mr. Dennis Taylor
8536102 d Avenue
Vero Beach, F132967
Dear Mr. Taylor:
Enclosed is City of Sebastian Certificate 2023 for the purchase of Cemetery Lot 17, Block 17,
Unit 4. Also enclosed is a copy of your receipt and the Rules and Regulations governing the
Sebastian Municipal Cemetery.
If you have any questions, please contact our office.
Si rely,
Y
Sally JAaio, MMC
City Clerk
SAM:ar
enclosure