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Certificate # 1867
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HC-ME OF PELICAN 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:
Susan J. Peters
(name)
(name)
(name)
(address)
in and for consideration of the sum of $1,900.00 ,has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plot:
Unit 4 ,Block 14 ,Lot(s) 16 & 17
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 6th day of November 2002 .
Y OF SEBASTIAN, FLORIDA
ence . Mo re
City Manager
P 0 Box 782145, Sebastian, F1 32978
(address)
(address)
ATTEST:
ally A. Maio, CMC
City Clerk
O -_ --
Name
Unit
Block ~~
Lot
Date of Mark-out
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Date of Burial ~j ~ 6~'',~ ~~ Time ~-
Name of Funeral Home ~ / /'G• L! /4~,1~
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CITY OF SEBASTIAN ~12 0 4
CITY CLERK'S OFFICE
RECEIPT
Name ~'~`"~ O Cash
Date ` Q eck # ~ ~~"
AmorurtPaid
001001 208001 Sales Tax ,
001501 322900 Garage Sales
001501 341920 Capies/Bid Specs.
001501 341910 LDC/Code of Ordinances
001501 362100 Community Center Rent
001501362100 Yacht Club Rent
001501 362150 Non Taxable Rent ~µ
001501 343800 Cemetery Lots ~~~~~~`!6~/7 ~ ~` V
601010 343800 Cemetery Lots
LotMiche ,Block ,Unit
001501 369400 Interment Fee
001501 369400 Weekend Service
680800 220681 Yacht Club Security Deposit
680800 220682 Community Center Security Deposit
680800 220683 Riverview Park Se~crurit/y Deposit
,.~~ Tohl Pald~ ~~ "' ~~ ~,
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Initlals
White - Dspt. of Origin • Yellow - Firana • Pink -Applicant
FLORIDA DEPARTMENT OF
HEALT
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL -TRANSIT PERMIT
q, (TYPE)
1. Name of First Middle Last Date Month Day Year
of
Deceased Erman Peters Death 11/02/02
Robert
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Vero Beach Inst. 8980 106th Avenue
3. Name of Medical Address Phone Number
Certifier Noor M. Merchant, M.D. 13060 U.S. #1
Med ical Examiner Physician Sebastian, FL 32958 (772) 589-0879
4. Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment 1623 North Central Ave.
Strunk Funeral Home Sebastian, Florida 32958 1228 (772) 589-1000
5. Check a. ~ The medical certification has been completed and signed
Appropriate application.
Box
b.
c.
BURIAL -TRANSIT PERMIT
He/she verified that
Medical Examiner, will complete and sign the
me c ation, ca of death within 72 hours.
6. Funeral Director/ natur F.E. No./Reg. No. Date Signed
Direct Disposer ~~' ~-/~-!'..-n-/1.! 1862 11 /04/02
B.
Permission is hereby granted to dispose of this body. Permit No. 122$-02-0453
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.
,~,* Date Date Certificate
Subregistrar Signature ~Qy]C/l~j ~.. ~~•~ Issued: 11 /04/02 Due: 11 /08/02
~~- ~
A completed certificate of death accompanies this
Dr. Merchant was contacted on 11 /04/02
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that He will complete and sign the medical
certification of cause of death within 72 hours.
~. 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 STORAGE
CREMATION OTHER
Signature of ~wll~sr• 1
/a l
~
Person-in-Charge J~L
J} C.
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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: While: Cemetery or Crematory
DH 326, 6/97 (Obsoleles all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number: 5740-000-0326-2) Pink: Local Registrar
CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemetery- -
was contacted on
Date of Disposition November 6. 2002