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HOME OF FEUGAN 1SWVD
Certificate # 1927
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian,
it is hereby certified that:
John H. and Carol B. Graves
(name)
(name)
398 Benchor Street, Sebastian, F1 32958
(address)
(address)
in and for consideration of the sum of $1,400.00 ,has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plot:
Unit 4 ,Block 15 ,Lot(s) 15 & 16
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 17th day of November ~ 2003
CITY OF SEB `STIAN F RIDA ATT T:
f `~
y°
T ce R.1VV~~re Sally A. M ' , CMC
City Manager City Clerk
l __ _ J
Name
Unit '7
Block
Lot ~ ~-
Date of Mark-out
,p e
Date of Burial l.~ ~~+~ Time >,~ ~
Name of Funeral Home ~ ,~.~~ ~
'--__'
Authorized by - , '
'~ i M~,~,,,,,~I Jades ~ ~.
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D
CRY OF SE IA
CRY CLERK'S OFFICE
RECEIPT
Name ~ -~~~~_;~° Cash/"
Date ~i~ /~ t~ g~CFieck # ~l
No. Amount Paid
001001 208001 Sales Tax
001501322900 Garage Sales
001501341920 CopieslBid Specs.
001501 341910 LDC/Code of Ordinances
001501341930 Election Qualifying Fees
601010 343800 Cemetery Lots s~,,//
LoUNiche Block Unit
001501 343805 Cemetery Fees ~ • Q~
--5.~ Total Pai~j~v / ~ d
Initials
White - Dept of Origin • Yellow -Finance • Pink • Applicant
F~`DA DEPARTMENT OF
I~EAL~'
A.
1. Name of
Deceased
State of Florida, Department of Health, Vital Statistics (~ D
APPLICATION FOR BURIAL -TRANSIT PERMIT ~,~/
First Middle Last Date Month Day Year
John H. Graves, Jr, of
Death Dec • 8 2003
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
ndian River Roseland inst. Sebastian River Medical Center
3. Name of Medical Address Phone Number
Certifier David DePutron, D.O. 13836 U.S. #1
Medical Examiner Physician Sebastian, FL 772-589-6888
t. Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment 1623 N. Central Ave.
Strunk Funeral Home Sebastian, FL 1228 772-589-1000
i. Check a. U The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. d Janice was contacted on 12/8/03
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. DePutron 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
ical c ' Ication of cause of death within 72 hours.
~. Funeral Director/ Ignat a F.E. No./Reg. No. Date Signed
Direct Disposer 1862 12/8/03
s. BURIAL -TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228-03-0499
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.
~gt~afef. Date Date Certificate
SubregistrarSignature~~,t~~, ~_ ~-'"'~'~3,~ Issued: 12/8/03 Due: 12/13/03
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)
CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemetery
Date of Disposition f,T ~ ~~~
nis 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
ithin 10 days to the local County Health Department in the county where disposition occurred.
Distribution: White: Cemetery or Crematory
1326, 6197 (Dbsoletes all previous editions) Yellow: Funeral Director or Direcl Disposer
lock Number/5/74/0~~0~00~0326-2) ~. - D //n ~/j~f~~ (//~ Pink: Local Registrar