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Certificate # 1947
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Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Nicholas M. & Carmen Jackson 1337 Scroll S�, Sebastian, F132958
(name) (address)
in and for consideration of the sum of 2 100.00 has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plot:
Unit 4_, Block 16 , Lot(s)_3, 4& 5_
of tbe 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 25th day of February, 2004.
OF ,ST�ASTIAN, FLORIDA
�rren� Moore
City Manager
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Sall� . Maio,
City Clerk
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Name �D 5 � /YI /9,� l �.� %� � 1..<.J L�, c...5 /`l � �, �V � �� iZ
Unit T
Block � �%
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Lot
Date of Mark-out ��� �a �'Y
,/ ,
Date of Burial � / � � ,�d '7' Time �� ' � � � '
Name of Funeral Home —.3 •� /9 Lc,� '� �7 5
% " ^ �� � � ,�, yy� �f
Authorized by '�/ �/���-'�'�'' ` ""-'
HEALT StaAPPLICATION FOR BUR AL HTaRAN IT PERMIT'cs
A. (TYPE)
1. Name of First Middle Last Date
Deceased of
RO SEMARIE P IWOWARCZYK Death
2. Place of Death City, Town or Location Name of (If neither, give street address)
County INDIAN RIVER VERO BEACH Hosp. or VNA HOSPICE HOUSE
I nst.
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�-/� -s
Month Day Year
3. Name of Medical Address Phone Numbei
CertifierRICHARD CUNNINGHAM, DO 3800 20TH STREET 72_7g4_222�
Medical Examiner X Physician VERO BEACH, FLORIDA 32960
4. Name of Funeral Home/Direct Disposal Address Fta. Lic. No./Reg. No. Phone No. (Area Code)
Estab�isnment 735 FLEMING STREET 2617 772-589-1933
SEAWINDS FUNERAL HOME SEBASTIAN FLORIDA
5. Check a. � The rnedicai certification has been completed and signed. A completed certificate of death accompani�6 this
Appropriate application.
Box
b� � 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.
�• � was contacted on He/she verified that
, Medical Examiner, will complete and sign the
medical certific on of cause of death within 72 hours.
i. Funeral Director/ ature F.E. No./Reg. No. Date Signed
Direct Disposer 2294 3/9,/04
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BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 04-2617-054
� A five (5) day extension of time far 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.
allo extension of time for filing the deat ertificate has been requested.
Registrar or Date Date Certificate
SubregistrarSignature Issued: 3/9/04 Due: 3/14/04
-. 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.
�. CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition���/,�;��,� ��G'�,� ��� .
� URIAL �STORAGE Date of Disposition �/i D/z� 3
��CREMATION
Signature of Sexton
or Person-in-Charge
�OTHER (Specify)
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his 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
ithin 10 days to the local County Heatth Department in the county where disposition occurred.
Dislributwn: White: Cemetery or Cremetory
1 326, B197 (Obsoletes all previous editiona) Yellow: Funeral DireIXor or Direcl Disposer
tock Number 5740-000-0326-2) Pink: Local Registrar
e
01 208001
01 322900
01341920
01341910
01341930
10 343800
01 343805
CITY OF SEBASTIAN
CITY CLERK'S OFFICE
RECEIPT
2616
A Cash
eck # ��
Amount Paid
Sales Tax
Garage Sales �
CopieslBid Specs.
LDClCode of Ordinances
Election (lualifying Fees
Cemetery Lots
LotlNiche , Block , Unit _
Ce tery Fees
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