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SEBMTE
HOME OF PELICAN ISLAND
r T X-13 1 0-0
Certificate # 1896
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian,
it is hereby certified that:
Marie J. Faraoni
(name)
(name)
199 S. Wimbrow 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) 25 & 26
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 Df Sebastian.
CONVEYED THIS 25thday of April 2003
CITN OF SEE TIAN, FLORIDA
Terrence R. re
City Manager
U
ATTEST:
r � .
Sally A. io, CMC
City Clerk
Name rpR POW Z �Qr "7' /x 1 �
Unit
Block r
Lot - I i
r�
Date of Mark -out
Date of Burial �/ Time �l ' oo
Name of Funeral Ho e-���
Authorized by ': C-' r�l�
f M 19-.T -AJ,5
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Unit
Block `4
Lot '
Date of Mark -out ' "% 0
Date of Burial s 03 Time Id ' 36 P127.
Name of Funeral H Me
Authorized byr
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DEPARTMENT OF
FLORIDA ii f
4. (TYPE)
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
1. Name of First
Middle
Last
Date
Month Day Year
Deceased ANTHONY
ANGELO
FARAONI
Of
APRIL 22, 2003
Death
2. Place of Death City, Town or Location
Name of (If neither, give street address)
County
Hosp. or
INDIAN RIVER SEBASTIAN
Inst. SEBASTIAN RIVER MEDICAL CENTER
3. Name of Medical
Address
Phone Number
Certifier RALPH GEIGER, 14D
13838 US 1
1772-581-6900
Medical Examiner %
Physician
SEBASTIAN,
FL 32958
I. Name of Funeral Home /Direct Disposal
Address
Fla. Lic. No. /Reg. No.
Phone No. (Area Code)
Establishment
735 F EMING STREET
SEAWIMS FUNERAL HOME
SEBASTIAN, FL 32958
2617
772 - 589 -1933
i. Check a. The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. 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,
C. was contacted on He /she verified that
, Medical Examiner, will complete and sign the
medical ge7ication of cause of death within 72 hours.
Funeral Director/ ign ture F.E. No. /Reg. No. Date Signed
Direct Disposer 2294 4/24/03
s. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 03- 2617 -053
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.
rlo extension of time for filing the death ce icat has been re ed.
Registrar or Date Date Certificate
Subregistrar Signature Issued: 4/24/03 Due: 4/25/03
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. A waiting period of 48 hours after death is
required for all cremations.
CEMETERY OR CREMATORY ��_
Method of Disposition: Place of Disposition S 1,1¢4 (2".� 114 1.
W F1
BURIAL STORAGE Date of Disposition
CREMATION OTHER (Specify)
Signature of Sexton 1
or Person -in- Charge J)
his 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, 8/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
tock Number: 5740- 000 - 0326 -2) Pink: Local Registrar
001
SEBASTIM
HOME OF PELICAN ISLAND
City of Sebastian Municipal Cemetery
Purchase Receipt
To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery
rate regulations, residence of purchaser or person for whom lot is intended for interment must be
provided at time of purchase
.4" _ s
Names)
Ad ess
FFZ)
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Receipt is acknowledged in the sum of:
Ilars ($
1
on this day of , 20 �� for the purchase of the following
described Cemetery Lot(s) add/or Niche(s).
Unit , Block , Lot(s) o76— - - ,,R 6 Niche(s)
for use in accordance with the conditions, ordinances, resolutions, rules and regulations
prescribed therefore by the City of Sebastian.
Additional Fees paid at time of purchase:
( ) 9 9 %5� c� C� W O H
Corner Markers set of 4 - $20 Opening & Closing
Circle One
Vase and Ring for Niches (cost) Interment
Signature of Purchaser
Disinterment
OTAL
Ity of Sebastian
Service fees are to be paid at time of need only
1: \W W- DATA \Ms- Cemetery\RECE IPT.doc