HomeMy WebLinkAbout4-16-14Name L� 1r�� � LLQ,/. 137.� � y I�� � �
Unit
Block
16
Lot
Date of Mark out
Date of Burial Time
A)k
57,� R Q
Name of Funeral Home
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r
Authorized by 4 -�`
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SEB�T�AIrI
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HOME OF PEUUN ISUWD
Certificate # 1977
�� � �'� � ,��� �������`T_�"��k;�.V
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Lowell J& Elizabeth D. Binckley 1544 Crowberry Lane, Sebastian, FZ 32958
(name) (address)
in and for consideration of the sum of 1400.00 has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plots:
Unit_ 4_ Block _16_ Lot(s)_13 & 14_
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 July, 2004.
City Manager
A S :
, � �---�_
Sal A. Maio, CMC
City Clerk
�
�O C�'�.
FLORIDA DEPARTMENT OF
HEALT
A. (TYPE)
1. Name of
Deceased
2. Place of Death
County
I ndian River
3. Name of Medical
Certifier C'a�
�t y- � i�" -- � � f
State of Flo�ida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
First Middle Last Date
of
Lowell Jerome Binckiey Death
City, Town or Location Name of (If neither, give street address)
Hosp. or
Vere gAach Inst. Atlant:.- 1-I�It1, ('��o
� �Medical Examiner �
4. Name of Funeral Home/Dire�t-Dtspvaal—
Establishment
Month Day Year
Dec. 1 2005
Address Phone Number
M.D. 1265 36th Street
nysician Vero Beach, FL 772-567-6340
Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
1623 N. Central Ave. � 228 772_589-1000
Strunk Funeral Home
5. Check a. � The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. � KathY was contacted on 12 /1 /05
He/she verified that this death was from natu�al causes, that there was no accident nor other extemal cause of death,
and that �r. Silverman will compiete and sign the medical
certification of cause of death within 72 hours.
c. �
was contacted on He/she verified that
, Medical Examiner, will complete and sign the
medi ifica ' n use of death within 72 hou�s.
6. Funeral Girector/ ign �.E. No./Reg. No. Date Signed
�"�'�°C°r 1862 12 1
e� BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228-05-0�95
� A five (5) day extension of time for filing the death certficate (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.
�� Date � Date Certificate
SubregistrarSignature � {1.... Issued:l2/1/05 Dye: 12/6/05
�� AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA
Approval Number: Date
Medical Examiner, , gave authorization by telephone to
Funeral DirectoNDirect Disposer. Date
The Medical Examiners approval must be obtained before disposal by any of the above methods. R waiting period of 48 hours after death is
required for all cremations.
�� CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition Sebastian Cemeter�r
I �
BURIAL �STORAGE Date of Disposition �� / f/0 5
�CREMATION
Signature of Sexton
or Person-in-Charge
�OTHER (Specify)
} �___�. ;
This pertnit 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, 8/97 (Obsoletea all previous edifions) Distribulion: ���. Funerel D'vector Dired Diaposer
(Stock Number. 5740-000-0326-2) Pink: Local Reyistrer �`� �
�ITY OF SEBASTIAN 3 0 2 7
CITY CLERK'S OFFICE
RECEIPT
N�me ❑ Cash
eck M��/�Z-t--�—
Date
Amount Paid
No.
001001208001 Sales Tax —
001501322900 Garage Sales
001501341920 CopieslBid Specs.
0015p� 34191p LDGCode of O�dinances
001501341930 Electlon Quali(ying Fees � �
601010 343800 Cemetery Lois
���`'--
LoUN�he�� Blodc !� . Unit�
001501343805 Cemetery Fees
'" d�
Total Paidl
Initials
Whit� — �ept. of Oripio • Yellow — Finmca • Pink • Applicant
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CITY OF SEBASTIAN
�� ��E�'S OFFICE 3 519
RECEIPT
ame.�es�'G9�,��,,, e�� ,����d`Cash
ate �, � _ a��J'� �heck# ��� �
', D.
)1001 208001
)1501 322900
11501 341920
)1501 341910
)1501 341930
)1010 343800
)1501 343805
Amount Paid
Sales Tax
Garage Sales
CopieslBid Specs.
LDCICode of Ordinances
Elecdon Qualifyirq Fees
Cemetery Lots
LoUNiche . Bbdc . Unit
Cemetery Fees �� J. D�
�/�,/ � /�//
L! /f' ' �� , �T
�?
Total Pai��� " � d
Initials
White - Dp� of O�iqin • YNlow - F9n�nee • Pink • Applic�nt
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