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aryOF
SFORASTKN
HOME OF PELICAN ISLAND
Certificate No. 2024
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:
Letitia Sargent 12970 74`h Court, Sebastian, Fl 32958
(name) (address)
in and for consideration of the sum of 7$ 00.00 has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plot:
Unit 4_ Block _17_ Lots _31_
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 28th day of June, 2005.
CITYPF SEBSTIAN, FLORIDA
Sally A. Oaio, MMC
Ci(v Clerk
G,
pin �
O
0
Name
Unit
Block
Lot
Date of Mark -out 7 A
Date of Burial Time
� J }
Name of Funeral Home
Y !k
Authorized by 't'
FLORIDA DEPARTMENT OF
HEALT
A. (TYPE)
State of Florida, Department of Health, Vital Statis ' PY
APPLICATION FOR BURIAL - TRANSIT PERMI
16 O
1. Name of
First Middle
Last
Date
Month Day Year
Deceased
of
Kiben Anthony
Sargent
June 24 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 Roger
E. Mittleman, M.D
C.M.E.
2500 S. 35th Street
Medical Examiner Physician
Fort Pierce, FL
772 -464 -7378
4. Name of Funeral Home /Dkac;.t Li;in *al
Address
Fla. Lic. No. /Reg.
(Area Code)
Establishment
1623 N. Central Ave.
=89-1000
Strunk Funeral
Home
Sebastian, FL
1228
5. check a. LJ The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. F-1 was contacted on
He /she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that will complete and sign the medical
certification of cause of death within 72 hours.
C. Te' was contacted on b I i lax He /she verified that
Medical Examiner, will complete and sign the
medical ce atio c se of death within 72 hours.
6. Funeral Director/ I atu F.E. No. /Reg. No. Date Signed
4acect'Ctsposer 2 6/27/05
B
BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228 -05 -0276
❑ 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.
Registrar or n Date Date Certificate
Subregistrar Signature P-'\r Issued: 6/24/05 Dye: 6/29/05
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 all cremations.
D. CEMETERY OR CREMATORY
WBURIAL od of Disposition: Place of Disposition Sebastian Cemetery
STORAGE Date of Disposition
CREMATION OTHER (Specify)
Signature of Sexton 1
or Person -in- Charge J
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
R�Iu. i .tee
e.
rn -a, / d e. es-al �D
4 e i, A,.
1 :L 4 70 7Y
Ze, ba. s 4A -j,
SAL66"r
r;L C44,4,�a~
►GL 32 9
STRU4K F=UNERAL HOME
1623 No. Central Ave.
SEBASTIAN. R. 32M
SEBASTE
w.
HOME Of yPEUCAN 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
Name(s)
/.Z 970 7�77� �'d � s %�.� �.l • .�
Address
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
is acknowledged in the sum of:
liars ($ %4 o a )
on this day of 20 ^S`for the purchase of the following
described Cemetery Lots) d /or Niche(s).
Unit, Block_, Lot(s) .3/ 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 - $20) Opening & Closing >;$e757D n (:--J— O H
Circle One
Vase and Ring for Niches (cost) Interment _z2N Disinterment
$ '5 . Q d
Signature of Purchaser My of Sebastian
Service fees are to be paid at time of need only
I: \W W- DATA \Ms - Cemetery\RECEI PT.doc
CRY OF
SE
HOME OF PELICAN 1SU1ND
1225 Main Street, Sebastian, 17132958
Telephone (772) 589 -5330 — Fax (772) 589 -5570
July 5, 2005
Ms. Letitia Sargent
12970 74`h Court
Sebastian, F132958
Dear Ms. Sargent:
C(OPY
Enclosed is City of Sebastian Certificate 2024 for the purchase of Cemetery Lot 31, 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.
Sinc rely,
Sally A. o, MMC
City Clerk
SAM:ar
enclosure