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Certificate # 1957
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Betty E. Reed
(name)
106 Osceola Avenue, Sebastian, FZ 32958
(address)
in and for consideration of the sum of 700.00 has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plot:
Unit _ 4_ Block _16 , Lot(s)_ 22 _
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 Apri12004.
Y OF SEBASTIAN, FLORIDA
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Terre�e R. Moore
City Manager
A ST:
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y A. Maio, CMC
City Clerk
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Name
Unit
Block
�
Lot � �
Date of Mark-out /� �d �
Date of, Burial �//� �,/� � Time / Q ' d D �• �C% �'�1�� '
�
Name of Funeral Hom 7.C� �/.cJ ��h S
,,� � � � ���, � u� �
Authorized by
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HEALT]
A. (TYPE)
1. Name of
Deceased
2
3
:f
5.
First
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
Middle Last
of — �.�./
Death 4_
ear
Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
INDIAN RIVER ROSELAND inst. SEBASTIAN RIVER MEDICAL CENTER
Name of Medical Address Phone Number
Certifier ADII� SANAULLA, 1rID . 13885 U. S. HWY 1
Medical Examiner X Physician SEBASTIAN, FL 32958 (772) 589-1933
Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment 735 FLEMING ST.
SEAWINDS FUNERAL HOME SEBATIAN, FL 32958 2617 (772) 589-1933
Check a. � The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
6. Funeral Director/
Direct Disposer
a
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.
c. � was contacted on He/she verified that
, Medical Examiner, wiil complete and sign the
certification of cause of death within 72 hours.
Signature F.E. No./Reg. No.
BURIAL - TRANSIT PERMIT
Date S�ned
��� Q
r
Permission is hereby granted to dispose of this body. Permit No. 04-2617-094
� 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 deat 'ficate has been requested.
egistrar or Date f Date Certificate
Subregistrar Signature Issued: ���/ "�� Due: ��p�. g-D y
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.
�. CEMETERY OR CREMATORY �
Method ot Disposition: Place of Disposition 5:' '� j= - •
' URIAL �STORAGE Date of Disposition / � �
�CREMATION
Signature of Sexton 1
or Person-in-Charge j
�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
within 10 days to the local County Health Department in the county where disposition occurred.
Distribution: White: Cemetery or Crematory
DH 326, 8197 (Obsoleles all previous editions) Yeilow: Funeral Director or Direct Disposer
;Stock NumDer 5740-000-0326-2) Pink: Local Registrer
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HOME OF V PELICAN ISIAND
City of Sebastian Municipal Cemetery
Purchase Receipt
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i�y
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
e, `�' � 2 �- e �
1� � � _ .
Name(s) ' D � � 5 C � C� l (� � � e- .S'L�o � ��t^�.J � `3zti��
�
Address � � 2 _ � � � � � � ;
/
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
OfiFice Use Only
is acknowledged in the sum o�
_�,yO�o�,�-�
Dollars ($ G� d, d�J )
on this day of , 20� for the purchase of the following
describe Cemetery Lot(s) and/or Niche(s).
Unit �, Block �_, Lot(s) aZ 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 ✓�� �� W O H
Circle One
Vase and Ring for Niches (cost) Interment
Disinterment
� ,S� Gd
Signature of Purchaser
of Sebasti
Service fees are to be paid at time of need only
I:\W W-DATA\Ms-Cemetery\RECEIPT.doc
No. � /
001001208001
001501322900
001501 341920
001501 341910
001501341930
601010 343800
001501343805
K
CITY OF SEBASTIAN -
CITY CLREERK' POFFICE 2 7 5 7
- ❑ Cash
�k #>�
Amount Paid
Sales Tax
Garage Sales �
Copies/Bid Specs.
LDCICode of Ordinances
Elecdon Qualifying Fees
Cemetery Lots C1,� ��
LoUNkhe,� Blod� � Unit �
Cemetery Fees �, j^t'10
L��L.
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l•� a,�� Total Paid � � v�
Initials
White — Dept. of Oripin • Yellow — Finence • Plnk - Applicont
�]Y OF
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HOME OF PELICAN ISUND
Apri128, 2004
Mrs. Betty E. Reed
106 Osceola Avenue
Sebastian, Fl 32958
Dear Mrs. Reed:
Enclosed is City of Sebastian Certiiicate Number 1957 for the purchase of Cemetery Lot 22,
Block 16, 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.
Sin rel ,
��E% � .
Sally A. aio, CMC
City Clerk
SAM:ar
enclosure