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HOME OF PELICAN lSIAND
Certificate # 1911
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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:
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(name)
(name)
(address)
(address)
in and for consideration of the sum of ~ 1, 4 0 0.0 0 ,has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plot:
Unit 4 ,Block 15 ,Lot(s) 11 & 12
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 THLS 2 6th day of August , 2 0 0 3
C Y OF S AST FLORIDA ATT
Yr
Terrence ~.Pvlfoore Sally A. l~Iztio, CMC r
City Manager City Clerk
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ice,;
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FLORIDA DEPARTMENT OF
Hy~ ~T ~ State of Florida, Department of Health, Vital Statistics O D
j~ j~ APPLICATION FOR BURIAL -TRANSIT PERMIT
A. (TYPE)
1. Name of First Middle Last Date Month Day Year
Deceased of
Donald Eugene McClure Death Au 30 2003
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
1 ndian River Sebastian Inst. 112 Tracy Drive
3. Name of Medical Address Phone Number
Certifier Frederick W ks, M.D. 1460 36th Street
Medical Examiner Physician Vero Beach FL 772-562-7777
4. Name of Funeral Home/Dkee!-BisFrO~al Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment 1623 N. Central Ave.
Strunk Funeral Home Sebastian, FL 1228 772-589-1000
5. Check a. ~ The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. Megan was contacted on 9/2/03
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. Weeks 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
medical ifica ' n usebf death within 72 hours.
i. Funeral Director/ n ur F.E. No./Reg. No. Date Signed
l~rest-8isflese r 1862 8 / 30 / 03
3. BURIAL -TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228-03-0362
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.
Fieg+sirar-ems Date Date Certificate
SubregistrarSignature ~,~y,[,~ ~. C~.a..~Z.Q Issued: 8/30/03 Due: 9/3/03
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.. 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.
Method of Disposition:
BURIAL
CREMATION
Signature of Sexton
or Person-in-Charge
STORAGE
OTHER (Specify)
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CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemetery
Date of Disposition ~~O ~/~
his permit must be endorsed by the Sexton orperson-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
-i 326, 8/97 (Dbsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
,rock Number: 5740-000-0326-2) Pink: Local Registrar
Name `~' i 3 P ,,° i 4 ;W .. G ~~ r ~, ~, 's -~
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Unit
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Block + ~y
Lot- ~4 ~°'
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Date of Mark-out ~~ ~ G ~` ~~'
Date of Burial
Name of Funeral Home r
- I ~.. ..
Authorized by
Time
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