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Certificate # 1876
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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:
Albert Cianciosi 225 Main Street, Sebastian F1 32958
(name) (address)
(name) (address)
(name) (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:
Unlt 4 , BIOCk 14 ,Lot(s) 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 26th day of February ~ 2003
Y OF ASTIAN, FLORIDA AT T:
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Terrence oore Sally A. ,~CMC
City Manager City Clerk
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Date of Mark-out
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Date of Burial - ~ _Time _ _ -
Name of Funeral Home, ~~ "~ ~~
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Authorized by ,
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CITY OF SEBASTIAN
CITY CLERK'S OFFICE "~ 5
- RECEIPT
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Date --~'~~~~
AmowrtPal
001001208001 Sales Tax
001501322900 Garage Sales
001501341920 Copies/Bid Specs.
001501341910 LDC/Code of Ordinances
001501 362100 Community Center Rent
001501362100 Yacht Club Rent
001501 362150 Non Taxable Rent
001501 343800 Cemetery Lots i
601010 343800 Cemetery Lots ~~ ~' II
LoVNiche ~, Block ~, Unit
001501 369400 Interment Fee ~ ~~~ ~''S` ~
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001501 369400 Weekend Service
680800220681 Yacht Club Security Deposit
680800 220682 Community Center Security Deposit ~
680800 220683 Riverview Park Security Deposit
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Initials
White - Oapt. of Origin • yellow - Finance • Pink • Appliant
FLORIDA DEPARTMENT OF ~ /~ ~/
ALT State of Florida, Department of Health, Vital Statistics V
HE APPLICATION FOR BURIAL -TRANSIT PERMIT `J
q. (TYPE)
1. Name of First Middle Last Date Month Day Year
Deceased of
Albert Charles Cianciosi Death Feb. 25 2003
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Vero Beach Inst. Alters Sterling House
3. Name of Medical Address Phone Number
Certifier Gary Silverman, M.D. 777 37th Street, #D103
Medical Examiner Physician Vero Beach, FL 772-770-0500
4. Name of Funeral Home/Birect•Btspt3591 Address 1623 N. Central Ave. Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment Sebastian, FL 1228 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 ~ Danielle was contacted on 2/26/03
He/she verified that this death was from natural causes, that,there was no accident nor other external cause of death,
and that Dr. Silverman 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 rtifi do f of death within 72 hours.
6. Funeral Director/ Sign u F.E. No./Reg. No. Date Signed
piraC.Dacpeeer~ 1862 2 / 25 / 03
B. BURIAL -TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228-03-0096
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 wilt 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 ~...... /~ ~ s Issued:2/25/03 Due: 3/1/03
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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.
D.
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 3/ / ~ J
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 returnee
within 10 days to the local County Health Department in the county where disposition occurred.
Distribution: white: Cemetery or Crematory
DH 326, 8197 (t]bsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number: 5740000-0326-2) Pink: Local Registrar