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THE SEBASTIAN CEMETERY
City of Sebastian
Sebastian, Florida
RECEIPT IS HEREBY ACKNOWLE ED OF THE SUM OF:
Dollars
FROM:
•-2
on this day of 198f for the purchase of the following
described Cemetery Lot(s) pon ihe terms and conditions as stated herein:
Description of Property: /
Cemetery Lot (s) #_ Block# ��? / Unit#
Purchase Price: `1�'�;', /,�i;} Dollars ($ )
Terms and'conditions of sale:
This contract shall be binding upon both parties, the seller and the purchaser, when
approved by the owner of the property above described.
I, or we, agree to purchase the above described property on the terms and conditions
stated in the foregoing instrument:
The City of Sebastian agrees to sell the above mentioned property,to the above named
purchaser(s) on the terms and conditions stated in the above instrument.
City of Sebastian
1�
Witness
Name _,7'`,X
Unit___,
Block— -r-
Lot
A- 7-
Date of Mark -out
R
Date of
Burial
Time
Name of Funeral Home `
''��..,'
Authorized by_
Paid by CEMETERY Receipt No...., ....... Dated .... 4
List Price $ ,150: 00 /Each I..3
..........
Maximum No. Purial Spaces ...... .
Net Paid s 300.00 2 Deed 11524 NU. 052
Monument permitted ..... flat- Archie Smith
............ P.O. Box 383
R & R ISSUED Sebastian, Florida 32958
- (Data *bore tbla line 'or tpty RMrd only)
LOTS 7 & 8, Bloc_ k 51, Unit #2 Add
STATE OF FLORIDA 71
W RTMENT OF HEALTH & REHABILITAT�ERVICES 5_1
VITAL STATISTICS
APPLICATION FOR BURIAL - TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
ARCHIE N /M /N SMITH DEATH September 20, 1986
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Sebastian Inst. Humana Hospital
3. Name of Medical
Certifier Farhat Khawaja, MD
Physician Address
Medical Examiner 7754 Bay Street - Suite 7- Sebastian Fl 32958
4. Funeral Home/ Name Address
ZWjV*0Wpdter Strunk Funeral Home 734 N. Central Avenue, Sebastian, Fl. 32958
5. Check a The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate .,,,. ', ,u, ,; Mare 9/22/86
Box � � S 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
Dr. George A. Mitchell will complete and sign the medical certification of
cause of death.
c was contacted on . He /she verified that
Medical Examiner, will complete and sign the
medical certification.
6. Funeral Director/ ignature Fla. Lic. No. /Reg. No. Date Signed
Direct Disposer
B. BURIAL— TRANSIT PERMIT Permit No. 1228 -86 -364
Permission is hereby granted to dispose of this body.
A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and
granted. If it cannot be filed within this time limit, a "Funeral Director /Direct Disposer Report" will be filed
with the Local Registrar of the County in which death occurred.
Registrar or Date��,..�Z.�r,
Sub- Registrar Signature Issued
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
e4.. -.. e....... tP�itPfY.. .:.♦
Signature Medical Examiner Date
or
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.
D. CEMETERY OR CREMATORY
Method of Disposition:
F] BURIAL Q STORAGE
CREMATION 0 OTHER (Specify)
Signature of Sexton ►
or Person -in- Charge 1
Place of Disposition
Date of Disposition
This permit must be endorsed by the Sexton or person -in- charge (or by i
and returned within 10 days to the local County Health Department in the
HRS Form 326, APR. 81
(replaces previous editions which may be used.)
ral E(joctor /Direct Disposer when there is no Sexton)
where disposition occurred.