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Certificate # 1908
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HOME OF PEUUN ISLAND
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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:
Harold V. & Lorraine Dacey
(name)
(name)
874 Carnation Drive, Sebastian, F1 32958
(address)
(address)
in and for consideration of the sum of $700.00 ,has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plot:
Unit 4 ,Block 15 ,Lot(s) 3
of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
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for use in accordance with the conditions, ordinances, resolutions, rules and regulations
prescribed therefore by the City of Sebastian.
CONVEYED THIS 5th day of August , 2003
CITY OF BASTIAN, FLORIDA ATTEST:
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errence .. ore Sad y A. M 'o, CMC
City Manager City Clerk
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HOME C)~ PELtCA.[V ISW~1D
August 5, 2003
Harold V. and Lorraine Dacey
874 Carnation Drive
Sebastian, Fl 32958
Dear Mrs. Dacey:
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Enclosed is City of Sebastian Certificate Number 1908 for the purchase of Cemetery Lot 3,
Block 15, Unit 4. Also enclosed is a copy of your receipt and the rules and regulations
governing the Sebastian Municipal Cemetery.
If you have any questions, please contact our office.
Sin ely,
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Sally A,~io, CMC
City Clerk
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enclosure
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HOME OF PELIUN .ISLAND
City of Sebastian Municipal Cemetery
Purchase Receipt
To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery
rate regulations, residence of purchaser or person for whom lot is intended for interment must be
provided at time of purchase
Name(s) _ ~'-`
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Address
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e & Phone Number
esidence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Recei is acknowledged in the sum of:
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Dollars ($ d0. o o )
on this ,.~ day of ~ , 20 ay~ for the purchase of the following
described Cemetery Lot(s) n r Niche(s).
Unit ~, Block ~, Lot(s) ,~,~ 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 T-~ O o
Vase and Ring for Niches (cost)
Signature of Purchaser
Interment
Disinterment
Service fees are to be paid at time of need only
W O H
Circle One
I:1W W-DATA\Ms-Cemetery\RECEIPT.doc
FLORIDA DEPARTMENT OF
H~~T ~ State of Florida, Department of Health, Vital Statistics
L APPLICATION FOR BURIAL -TRANSIT PERMIT
a. (TYPE)
I. Name of First Middle Last Date Month Day Year
Deceased of
Harold Vincent Dacey Death July 29 2003
?. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
1 ndian River Vero Beach Inst. Indian River Memorial Hospital
s. Name of Medical Address Phone Number
Certifier David R. Biezunski, M. D. 1600 36th Street
Medical Examiner Physician Vero Beach, FL 772-569-6112
,. Name of Funeral Home/DdFesF~B+s~esalr Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establisnment 1623 N. Central Avenue
Strunk Funeral Home Sebastian, FL 1228 772-589-1000
i. Check
Appropriate
Box
a. U The medical certification has been completed and signed. A completed certificate of death accompanies this
application.
b.
Laura was contacted on 7/30/03
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. Biezunski will complete 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 I ertif ati f cause of death within 72 hours.
Funeral Director/ Si a F.E. No./Reg. No. Date Signed
BURIAL -TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228-03-0311
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 death certificate has been requested.
Regtsrtr~---~ Date Date Certificate
SubregistrarSignature ~..• ,tom /~,l t;?/~,.~~Q Issued: 7/29/03 Due: 8/2/03
T
,. 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. Awaiting period of 48 hours after death is
required for all cremations.
thod of Disposition:
BURIAL
^CREMATION
Signature of Sexton
or Person-in-Charge
STORAG E
OTHER (Specify)
CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemetery
Date of Disposition ~ f r~~}
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
rithin 10 days to the local County Health Department in the county where disposition occurred.
Distribution: White: Cemetery or Crematory
-1326, 8/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
Mock Number: 5740-000-0326-2) Pink: Local Registrar