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Certificate No. 2193
ITY OF SE13ASTIANI
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Betty Preece 615 N. Riverside Drive, Indialantic, FL 32903
(name) (address)
In and for consideration of the sum of $6,000.00 is entitled to full interment
rights in the Sebastian Municipal Cemetery for the following lots:
Unit 4, Blk 11, Lots 11, 12y 13
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 26th day of September, 2008.
CITY OF S BASTIAN, FLORIDA
Al Minner
City Manager
lam'•
Sally A�t�laio, MMC
Citv Clerk
Nam�
Unit
Block
Lot *,
Date of Mark -out
� o ,r� -- c Time
Date of burial -� -� %`' -�
Name of Funeral Home 0 L&>
Authorized b
Auth o y
FLORIDA DEPARTMENT OF
HEALT
A (TYPE)
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
1. Name of First
Middle Last
Date
Month Day Year
Deceased
of
Betty Peters Preece
Death
May 17, 2009
2. Place of Death City, Town or Location
Name of (If neither, give street address)
County
Hosp. or
Brevard Indialantic
Inst. 615 North Riverside Drive
3. Name of Medical
Peter Marzano, M.D.
Address 1130 Hickory Street
Phone Number
Certifier
Medical Examiner Physician
Melbourne Florida 32901
321- 725 -4500
4. Name of Funeral Home /Direct Disposal
Address
Fla. Lic. No. /Reg. No.
Phone Number (Area Code)
Establishment
1010 E. Palmetto Avenue
Brownlie - Maxwell Funeral Home
Melbourne, Florida 32901
0000049
321/723 -2345
5. Check
Appropriate
Box
a. The medical certification has been completed and signed. A completed certificate of death accompanies this
application.
Sebastian Cemetery
C. C
Celia @ Dr. Marzano's Office was contacted on 5/18/09
He /she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. Marzano 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
medical certification of cause of death within 72 hours.
6. Funeral Director / ,.Si ture F F Nn iRPn Nn Date Sinned
Direct Disposer -\ F044250 May 18, 2009
B. ✓ BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 49- 2009 -169
®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 eath certi ate has been requested. May 18, 2009
Registrar or Date Date Certificate
Subregistrar Signatur- Issued: Due:
C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA
Approval Number: Date
A
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.
Method of Disposition:
® BURIAL
❑ CREMATION
Signature of Sexton t
or Person -in- Charge f
❑ STORAGE
❑ OTHER (Specify)
CEMETERY OR CREMATORY Sebastian Cemetery
Place of Disposition Sebastian, Florida
Date of Disposition - _ Z30 Z,'
This permit must be endorsed by the Sexton or person -in- charge (or by the Funeral Director /Director Disopser when there is no Sexton) and returned
within 10 days to the local County Health Department in the county where disposition occurred.
DH 326, 8/97 (Obsoletes all previous editions) Distribution: White: Cemetery or Crematory Yellow. Funeral Director or Direct Disposer
(Stock Number: 5740- 000 - 0326 -2) Pink: Local Registrar
CITY OF SEBASTIAN
CITY CLERK'S OFFICE /,
RECEIPT 4
Name_ C, Aka,�i ❑ Cash
Date Check# �+
No. Amount Paid
001001 208001 Sales Tax
001501322900 Garage Sales
001501341920 Copies/Bid Specs.
001501341910 LDC /Code of Ordinances
001501341930 Election Qualifying Fees
601010 343800 Cemetery Lots
Lot/Niche-/a Block_, Unit
001501343805 Cemetery Fees Cv
Total Paid 3t
Initials
White - Dept. of Origin • Yellow - Finance • Pink • Applicant