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HOME OF V PELIGN ISUND
Certificate # 1945
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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:
Siria and Jose Mendez 153 N. Maple Street, Fellsmere, Fl 32948
(name) (address)
in and for consideration of the sum of 1$ ,900.00 has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plot:
Unit 4_, Block _16 , Lot(s)_9 & 10 _
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 lOth day of February, 2004.
Y OF S ASTIAN, FLORIDA
;
/ , ,; � ,.
erre e R. Moore
City Manager
ATTEST:
t.�C.
Sal A. Maio, CMC
City C1erk
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Name d�) /' l'� I � ! � � .� 1� �' '��X t d .3 �7,�� � :
�/ Unit
Block � �
Lot � � —
Date of Mark-out
��������
��i�/n,� �� GD ��
Date of Burial ,� Time
Name of Funeral Home�x �// /' U r2,c�
Authorized by
�
No. �
001001208001
001501322900
OOt501 341920
001501 341910
001501341930
601010 343800
001501343805
CITY OF SEBASTIAN
` CITY CLREERK' POFFICE � � �
� Cash
eck
Amount Paid
Sales Tax
Garege Sales
Copiesl8id Specs.
LDC1Code of Ordinances
Election Qualifying Fees
Cemetery Lots
loUNiche . Biock . Unit
Cemetery Fees . �� `O d
`
Total Paid /�
Initiais �
White - Dept. of Origin • Yellow - Finance • Pink • Applicent
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2.
3.
4
PLORIDA DEPARTMENT OF
HEALT State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
/�-/�-/�
Name of First Middle Last Date Mon�h D� Year
Deceased of
Beatriz V. Cano Deatn February 12, 2004
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
Name of Medical Muham�ad Faroog, MD Address ��� 37th Street, Su�te A-104 Phone Number
Certifier
Medical Examiner % Physician oero Beach, Florida 32960 72-567-2277
Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment 1950 20th Street
5. Check
Appropriate
Box
6. Funeral Director/
Direct Disposer
B
c
a. � The medical certification has been completed and signed. A completed certificate of death accompanies this
application.
b� � Dr. Muha�ad Faroo� was contacted on February 12, 2004
He/she verified that this death was from naturai causes, that there was no accident nor other external cause of death,
and that },P will complete and sign the rnedical
certification of cause of death within 72 hours.
c. � was contacted on He/she verified that
, Medical Examiner, will complete and sign the
medical certification of cause of death yyithin 72 hours.
F.E. No./Reg. No.
���
BURIAL - TRANSIT PERMIT
Date Signed
rv 12, 2004
Permission is hereby granted to dispose of this body. Permit No. 1423-029-04
� A five (5) day extension of time for filing fhe 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 medicai certification of cause-of-death section of the death certificate within
72 hours.
Q�No extension of tirne for filing the death certificate has been r ested.
�� ��Registrar or �. Date Date Certificate
Subregistrar Signature Issued:Februar9 12, 2004Due: February 17, 2004
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.
p. CEMETERY OR CREMATORY
�
Method of Disposition: Place of Disposition ,�.� '��;� �� 1 ,�.i.��,_��'``?�
BURIAL �STORAGE Date of Disposition Z. ^ l�� `-� t''�
�CREMATION
Signature of Sexton
or Person-in-Charge
�
�OTHER (Specify)
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
�vithin 10 days to the local County Health Department in the county where disposition occurred.
Distribution: White: Cemetery or Cremetory
�H 326, 8/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
Stock Number 5740-000-0326-2) Pink: Local Registrar