HomeMy WebLinkAbout4-14-18�J
(COPY
rnr or
SEIDAST_"
HOME OF PELICAN ISLAND
CITY OFSE
Certificate # 1877
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian,
it is hereby certified that:
Michael J. Quagliano
(name)
Michael R. Quagliano
(name)
(name)
142 Day Drive, Sebastian, F1 32958
(address)
142 Day Drive, 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 14 'Lot(s) 18 & 19
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 27th day of February, 2003. !I
ITY SEBASTIAN, FLORIDA ATTEST:
errencfNloore ' A. M , CMC
City Manager City Clerk' i!
i
- - -- - --
FLORIDA DEPARTMENT OF
HEALT
A (TYPF)
o
State of Florida, Department of Health, Vital Statistics a
APPLICATION FOR BURIAL - TRANSIT PERMIT
1. Name of First Middle
Last
Date
Month Day Year
Deceased
of
VIRGINIA A.
QIIAGLIANO
Death
FEBRUARY 26, 2003
2. Place of Death City, Town or Location
Name of
(If neither, give street address)
County
Hosp. or
INDIAN RIVER VERO BEACH
Inst.
INDIAN RIVER MD ORIAL HOSPITAL
3. Name of Medical
Address
Phone Number
Certifier WILLIAM T. MCGARRy, MD
1460
36TH STREET
Medical Examiner FIlPhysician
VERO
BEACH, FL 32960
772 - 562 -7777
4. Name of Funeral Home /Direct Disposal
Address
Fla. Lic. No. /Reg. No.
Phone No. (Area Code)
Establishment
735 FIMIING ST
SEAWINDS FUNERAL HOME
SEBASTIAN,
FL 32958
2617
772 - 589 - 1993'
5. Check a. ® The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
E'
C. ❑
was contacted on
He /she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that will complete and sign the medical
certification of cause of death within 72 hours.
was contacted on He /she verified that
, Medical Examiner, will complete and sign the
medical cVffication of cause of death within 72 hours.
6. Funeral Director/ igna re F.E. No. /Reg. No. Date Signed
Direct Disposer WA 2294 2/28/03
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No.03- 2617 -024
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 ath certificate has been requested.
Registrar or Date Date Certificate
Subregistrar Signature Issued: 2/28/03 Due: 3/4/03
C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA
Approval Number: — Date
Medical Examiner, gave authorization by telephone to
Funeral Director /Direct Disposer. Date y �
The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting period of 48 hours after death is
required for all cremations.
D. CEMETERY OR CREMATORY r
Method of Disposition: Place of Disposition 15,4 4
BURIAL STORAGE Date of Disposition 313 / /c,
CREMATION 1-10THER (Specify)
Signature of Sexton 1
or Person -in- Charge 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 returned
within 10 days to the local County Health Department in the county where disposition occurred.
Distribution: White: Cemetery or Crematory
DH 326, 8/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number. 5740- 000- 0326 -2) Pink: Local Registrar C(
CITY OF SEBASTIAN
CITY CLERK'S OFFICE 15 2
RECEIPT
Name 1 ❑ Cash
Date — Check ff_
Amount Palo
001001 208001
Sales Tax
001501 322900
Garage Sales
001501341920
Copies/Bid Specs.
001501 341910
LDC /Code of Ordinances
001501 362100
Community Center Rent
001501 362100
Yacht Club Rent
001501 362150
Non Taxable Rent
001501 343800
Cemetery Lots
n�
601010 343800
Cemetery Lots
Block Unit
Lot/Niche _,
,
J
d �i��r'•
001501 369400
Interment Fee
t �"
001501 369400
Weekend Service
680800 220681
Yacht Club Security Deposit
680800 220682 Community Center Security Deposit
680800 220683 Riverview Park Security Deposit
I) Total Paid
I itials
White - Dept, of Origin • Yellow - Finance • Pink • Applicant
s
1�
Name
Unit
Block
Lot
Dr
Date of Mark -out
Time !
Date of Burial _ {
Name of Funer
Authorized by