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HomeMy WebLinkAbout4-17-20SLDASTIAN aa HOME OF PELICAN ISLAND Certificate No. 2014 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: Isaac D. Cathey (name) 9844 Riverview Drive, Micco, Fl 32976 (address) in and for consideration of the sum of $2,250.00 has purchased and is entitled to full interment rights in the Sebastian Municipal Cemetery for the following plot: Unit _4 Block 17 Lots 19 & 20 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 21st day of April, 2005. CITY OF SEBASTIAN, FLORIDA _ /11,44 - James A. Davis Interim City Manager ATTEST: )fk Sall A. Maio, MMC City Clerk Name cJ /i.'` c) J eAk7-71f71 (6 •+t1l�S, Unit / Block / 7 Lot • � �/�' tA) /4. A c,F. Date of Mark -out /i3 /i( /3//( Time :oo • (?/49111,7i5IM) Date of Burial Name of Funeral Home Authorized by • /'1"`1,,1 y. 60216 VI s H z 'Z7 z Ct) 2 C7 � 8 rn rT ,.0 H Crl r ri ,INV1?IOdWI 0 tTi r m r~ v o D • in in z r 0 > O rD z r. co o B ro rD • y CID 0 CO 3 Ul 0 c C09£17£ 105100 o g °o °o o °0 0 c Q 0 v cn (n 0 0 0 4.• . Jcs _ (O (D CO O O saaj 6u!Ij!Ienp uolloal3 saoueulpmO 10 epo3/3 1 CO P N O co co CO N O O O O � n 0 3 0 El 0 n s ar ot okn <31 1.,.1 W O CO 0 Z N d r• r• w o w (D r• Z m tr �Na) NI to ct k W W ` a • n O N (D ly N. rP \ m 0 0 v 1N3W31V1S '. \:. to, j � .� ts, 'N 'N.. -'\\IIC b, IC% I I o • Z% a . 1 rC 3 0 El 0 n s ar ot okn <31 1.,.1 W O CO 0 Z N d r• r• w o w (D r• Z m tr �Na) NI to ct k W W ` a • n O N (D ly N. rP \ m 0 0 v 1N3W31V1S APPLICATION AND PERMIT FOR DISPOSITION OF HUMAN REMAINS USE BLACK INK ONLY -MAKE NO ERASURES, WHITEOUTS OR OTHER ALTERATIONS 1A. NAME OF DECEDENT -FIRST (GIVEN) II 1B. MIDDLE � 1C. LAST (FAMILY) JAMES ; DALTON ; CATHEY 2. DATE OF BIRTH MONTH, DAY, YEAR 10 -12 -1946 3. DATE OF DEATH MONTH, DAY, YEAR 12- 31 -199C 4. SEX M 5A. CITY OF DEATH � 5B. COUNTY OF DEATH - OUTSIDE CALIFORNIA, ENTER STATE LOS ANGELES 1 LOS ANGELES 6. NAME, RELATIONSHIP, MAILING ADDRESS AND ZIP CODE OF INFORMANT MARC E. GREENE - EXECUTOR 3233 WONDER VIEW DR. LOS ANGELES CA 90068 7A. TYPED NAME AND ADDRESS OF APPLICANT -FUNERAL DIRECTOR OR PERSON ACTING AS SUCH FOREST LAWN HOLLYWOOD HILLS MTV'. � 7B. CALIFORNIA LICENSE NUMBER -IF APPLICABLE F904 ACKNOWLEDGMENT OF APPLICANT I hereby acknowledge as applicant that the proposed disposition stated herein is one of the dispositions authorized by Section 10376 of the Health and Safety Code, and was authorized pursuant to Section 7100 of the Health and Safe Code. A SIG rL URE OF APP ' ect or Person ti g'as Such i 8B . DATE SIGNED L ( /� - I i17 -q • PERMIT AUTHORIZATION OF LOCAL REGISTRAR ANY CHANGE IN DISPOSI- TION REQUIRES A NEW PERMIT TO SHOW FINAL DISPOSITION. THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVI- SIONS OF THE CALIFORNIA HEALTH AND SAFETY CODE AND IS THE AUTHORITY FOR THE DISPOSITION SPECIFIED IN THIS PERMIT. NOTE: THIS PERMIT GIVES NO RIGHT OF DISPOSAL OUTSIDE OF CALIFORNIA. 9A. AMOUNT OF FEE PAID 98. DATE PERMIT IS ED 9C. SIGNATURE OF LOCAL REGISTRAR ISSUING I 1 IjAs 9 7.00 I ' ► I 9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH- 19E. ADDRESS OF REGISTRAR OF DISTRICT OF DISPOSITION- IF DEATH OCCURRED IN CALIFORNIA 1 IF DISPOSITION IS TO OCCUR IN ANOTHER DISTRICT IN CALIFORNIA 1 313 NO.FIGUEROA,LOS ANGELES,CA.90012� 10. TYPE OF DISPOSITION(S) AUTHORIZED CHECK ALL APPLICABLE ITEMS E] A. BURIAL (INCLUDES ENTOMBMENT) ❑ D. SCIENTIFIC USE ❑ G. SHIP IN TO CALIFORNIA H. TRANSIT TO OUTSIDE OF CALIFORNIA ❑ B. CREMATION ❑ E. TEMPORARY ENVAULTMENT ❑ C. DISPOSITION OF CREMATED REMAINS OTHER ❑ F. DISINTERMENT THAN IN A CEMETERY FOR CORONER'S USE ONLY ❑ I. DISPOSITION PENDING INTERMENT 11A. NAME AND ADDRESS OF CEMETERY CITY CEMETERY, SEBASTIAN,FLORIDA 111B. DATE INTERRED' SIGNATURE OF PERSON IN CHARGE OF INTERMENT 1 1► 8 L CREMATION n Q 12A. NAME AND ADDRESS OF CREMATORY NA 12B. DATE CREMATED ' 12C. SIGNATURE OF PERSON IN CHARGE OF CREMATION I I ► D 2 SCIENTIFIC USE 2 13A. NAME AND ADDRESS OF FACILITY RECEIVING REMAINS NA ' 13B. DATE RECEIVED' 13C. SIGNATURE OF PERSON IN CHARGE OF FACILITY 1 I I ► .0 .0 i TRANSIT 2 D J 14A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE REMAINS OR CREMATED REMAINS ARE TO BE SHIPPED NA 14B. DATE SHIPPED 1 14C. ADDRESS AND SIGNATURE OF PERSON IN CHARGE 1 OF TRANSIT 1 I ► SCATTERING AT SEA DISPOSITION OTHER THAN IN A CEMETERY 15A. ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION SUFFICIENT TO IDENTIFY FINAL PLACE AND DISTRICT OF DISPOSITION 156. DATE OF 115C. SIGNATURE OF PERSON IN 1 15D. LICENSE NUMBER DISPOSITION CHARGE OF DISPOSITION I OF CREMATED RE- 1 1 MAINS DISPOSER 1 I I -IF APPLICABLE NA COPY 1 OF THE PERMIT ACCOMPANIES THE REMAINS TO THE STATED PLACE OF DISPOSITION. THE PERSON IN CHARGE OF DISPOSITION IS RESPONSIBLE FOR COMPLETING AND FORWARDING THE PERMIT WITHIN 10 DAYS OF DISPOSITION TO THE REGISTRAR OF THE DISTRICT IN WHICH DISPOSITION OCCURRED OR THE DISTRICT NEAREST THE POINT WHERE THE CREMATED REMAINS WERE SCATTERED AT SEA. THE LOCAL REGISTRAR MAY DESTROY ANY ORIGINAL OR DUPLICATE PERMIT AFTER ONE YEAR FROM ISSUE DATE. COPY 1 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF STATE REGISTRAR VS9 (REV.5 /89) FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY FUNERAL HOME: ADDRESS: PHONE #: SEcKLAlV now cm rtuCANnwe For information contact: Kip Kelso - Cemetery Sexton Sebastian Municipal Cemetery (772) 589 -2545 • City Clerk's Office City Hall, 1225 Main Street Sebastian, FL 32958 Office (772) 388 -8215 or 388 -8214 Fax: (7721589-5570 (Che ne) __QPEN BURIAL LOT Lot 2c Block i 7 Unit OPEN CREMAINS LOT Lot __ Block Unit _OPEN COLUMBARIUM NICHE Niche Block Unit BURIAL DATE AND SERVICE TIME: (P /3// // :10 . FOR DECEASED: NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownersh e- � 04-\nw Name c / Sign - ure W Date I 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 SIGNATURE OF LICENSED FUNERAL DIRECTOR. hi/ Name Signature Date Cemetery Sexton Certification: I certify that I have checked the ownership information by viewing the owner's deed and confirming with Clerk's office and that all fees have been paid Ce eter Sexton 6/3/ Date This form to be provided to Clerk's Office by Sexton for permanent record upon completion. Name .4/ Unit Block Lot ' Date of Mark-out Date of Burial .0.//„- 5- / 0 Name of Funeral Home Authorized by Time CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT 3299 Date //7 :.5 0 Cash No. 7 Amount Paid 001001 208001 Sales Tax 001501 322900 Garage Sales 001501 341920 Copies/Bid Specs. 001501 341910 LDC/Code of Ordinances 001501 341930 Election Qualifying Fees 601010 343800 Cemetery Lots Lot/Niche . Block . Unit 001501 343805 Cemetery Fees /° 5. v Total Pal Initials White - Dept. of Origin • Yellow - Finance • Pink • Applicant (TYPE) State of Florida, Department of Health, Vital Statistics APPLICATION FOR BURIAL - TRANSIT PERMIT 1. Name of First Middle Last Deceased Grace F. Cathey Date Month Day Year of Death May 7 2005 2. Place of Death City, Town or Location County Brevard Micco Name of (If neither, give street address) Hosp. or Inst. 9844 Riverview Drive 3. Name of Medical Certifier Frederick Peterson, M.D. Medical Examiner MPhysician Address 6100 Minton Road, N.W. Palm Bay, FL Phone Number 321 -724 -1172 4. Name of Funeral Home /DirdaGt-14iepeset" Establishment Strunk Funeral Home Address 1623 N. Central Ave. Sebastian, FL Fla. Lic. No. /Reg. No. 1228 Phone No. (Area Code) 772- 589 -1000 5. Check Appropriate Box a. ED b. c. D The medical certification has been completed and signed. A completed certificate of death accompanies this application. Vanna was contacted on 5/9/05 He /she verified that this death was from natural causes, that there was no accident nor other external cause of death, and that Dr. Peterson will complete and sign the medical certification of cause of death within 72 hours. was contacted on He /she verified that medical certification of cause of death within 72 hours. , Medical Examiner, will complete and sign the 3. Funeral Director/ Di*eet•Di3peeer Signature F.E. No. /Reg. No. Date Signed 1862 5/7/05 3. BURIAL - TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No. 1225-05 -0206 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. ONo extension of time for filing the death certificate has been requested. iiegistrartrr - Date Date Certificate SubregistrarSignature �,� — Issued: 5/7/05 Dye: 5/12/05 c. 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. A waiting period of 48 hours after death is required for at cremations. D. CEMETERY OR CREMATORY Method of Disposition: EBURIAL STORAGE DCREMATION DOTHER (Specify) Signature of Sexton or Person -in- Charge 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) (Stock Number. 5740 -000- 0326 -2) Distribution: White. Cemetery or Crematory Yellow: Funeral Director or Direct Disposer Pink: Local Registrar Grace r. Cathey, Micco Grace F. C:,they, 82, died May 7, 2005, ai her home. She was boi i in Miami and moved to ./Iicco 18 years ago, ,coming ft Jm her birth- place -:. She was a .. retary for 25 years at Cath. y Contractors Inc., Miami. She was a member of the Methodist faith, Moose Lodge and the Little Holly- wood Home Owners Associa- tion. Survivors include her hus- band of 61 years, Isaac "Joe" Cathey; Wayne Allen Cathey of Miami; sister, Mildred Persons of Lake Mary; and two grandsons. She was preceded in death by her son, Dalton Cathey. SERVICES: The funeral will be at noon May 14 at the Strunk Funeral Home, Sebas- tian, with the Rev. Gary Isner officiating. Interment will follow in Sebastian Cem- etery, Sebastian.