HomeMy WebLinkAbout3-COL-27SnBCRY OF
5ERAAN
HOME OF PELICAN ISLAND
Certificate No. 2220
CITY OF SEB ST1AN
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Joan M. Reale 7545 Agawam Road, Micco, FL 32976
(name) (address)
In and for consideration of the sum of $2,400.00 is entitled to full interment
rights in the Sebastian Municipal Cemetery for the following niche:
Al Minner
City Manager
Unit 3, Col, Niche 27snb
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 11th day of May, 2009.
CITY OF SE:ASTIAN, FLORIDA ATTEST
Sally Maio, MMC
City Clerk
Name
Unit
Block e.002
Lot
Date of Mark -out
Date of Burial
Authorized by
Tdr eALlefifigS
A tiie s ht(
Name of Funeral Home
CERTIFICATE OF CREMATION
SYRACUSE, NEW YORK
The undersigned, being on this date
in charge of the Oakwood Cemeteries Crematory,
hereby certifies that the remains of
No.09 -837 By
Joan M. Reale
were cremated on the 23" day of June 2009; that the
Burial Permit, prerequisite to the cremation of the remains,
accompanied same and shows June 22. 2009 as the
date of death, Natural Cause as the cause and 71 as the age.
Authorized Representative: Oakwood Cemeteries, Inc.
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of my knowledge, death occurred at the time, date and Is
License No.: ce
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O ONUNK8 Mc 0 :4 Means Physician 0 Physician Wing on behalf of Attend q Physician
1 Comma 2 Medical Examiner Deputy Medical Examiner
ON. N WON is hot telrysidm.e CoTO(lasPaysrtiiAY
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CERTIFICATION: T
Cereler'a Name
nd due to th
231 DA FILE
YS I i rs COMPLE TE:0 BY 6ERTIFYUIti rUY6If7tAN?" OR
RESIDENCE
NC
4A PLACE OF DEATH: HOSPITAL AL HOSPITAL
/COMA One) D0A ER OUTPATIENT INPATIENT
0 0
NAME OF FACILITY: (Unot (achy, give address)
NURSING
HOME
A 1L! NAME OF FIRST MI LAST
FATHER:
HOSPICE
FACILITY
1 7A. CITY ARO STATE OF BIRTH: (N not USA. Country and
t Region/Province)
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NEVEI Ida 7 :L.J 4 SE 51
1St usuAL OCCUPATION: (Do not enter aired) 1 158. KIND OP BUSINESS OR INDUSTRY:
I
2. M.
GALE FEMALE MONTH DAY
IrM
40 IF FACILITY. DATE ADMITTED.
MONTS
3A. DATE OF DEATH:
200. LOCATION: (Marlow(
4E. COUNTY OF DEATH:
35. HOUR
nr r
21B. GIS T10N NUMaER:
220. REGLSTMTION NUMBEIL
1 YES
011•1961 (100005)
CONFIDENTIAL
W DEAN WAS CAUSED 8Y:'(E2TER ONLY ONE CAUSE PER LINE FOR (A). (e). AND (CI.)
PART 1. IMMEO)ATE CAUSE:
TO OR AS A CONSEQUENCE OF.
p DUE TO OR ASACONSEOUENCE
LL
w PART IL OTTER SIGNIFICANT CONDITIONS CONTRIBUTING TO
en DEATH BUT NOT RELATED TO CAUSE GIVEN IN PART I (A):
tg
C 31iw INJURY. DATE: M
I HOUR:
NEW YORK STATE
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
AO
45 M D N0. 4G. WAS DECEDENT TRANSFERRED FROM ANOTHER INSTITUTION? (II yes. spec institution unit city or
NO YES
h
11: BE5EBENP&EPJCAT10N; Lane M eer wameseaMNeneopratNpwe orM WermWbrawmNNedael doom.
I❑selhpeade 20 9m•t hcracknodiplamA 3 on* scMd graduate m GED
d Same college medic bd nodes ee 5 Assodate's degree 6 Bachdoes degree
7 Meth%dere a Dogdawo oiessiael degree
318. INJURY LOCALITY: (City or loan and county and stale)
SEE INSTRUCTION SHEET FOR COMPLETING CAUSE OF DEAT
3IC. UESCRIBE HOW INJURY OCCURRED:
county and state)
78. IF AGE UNDER 1 YEAR. NAME OF HOSPITAL OF
816TH:
10. 0E 86615 RACE: Cheek we mew s loinanx alai woHakamNi Oared CirNewafwsWMbe'
A CHWIeekancesian B 0 Mack or Mean American
E Fnpino F Japanese
J NaWe Hawafan K 6uamanun or Chmorro
N❑ MOM Iidunw Alaska Na0re(glen
P Other Asian (spenry)
S crier (specify)
3
STATE FILE PFUMBEF
C Asian Tendon DM Chinese
G Korean H Vietnamese
Al Samnan
a Omer Paclbc Islander (specify)
ir it i
WmoN CITY OR VILLAGE UMITS?
'OYES ONO IF NO, SPECIFY TOWN:
CONFIDENTIAL
APPNOI'M WE DIMI NO/
IEIWEEN ONSET AND OEM
TOBACCO USE CONTRIBUTE TO'DEATN?
r i 0 NO 1 YES 2 PROBABLY 3 UNKNDwN
R' aK
OF INJURY: r 31E. INJURY AT WORK?
NO YES
N
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, proof of City residency of purchaser or person for whom lot is intended for interment must
be provided at time of purchase.
Jciv n'l 122a l e.
Name(s) 5q5 aL,JQ.I'Ym ,Oast, m l c O, /L 3 2q 7 C
Addres �J
4 f l�
Area Code Pho a Number
Name Residence Address of Intended Occupant if Other Than Purchaser
Receipt is acknowledged in the sum of:
JWD 6vnd, ..hiwytd/zici o %s a.,g00. p O
Signature of Purchaser
I \W W- DATA\Ms- Cemetery\REC E I PT. doc
OFFICE USE ONLY
on this day of 20 for the purchase of the following described
Cemetery Lot(s) and /or Niche(s).
Unit 3 Block e_cl Lot(s) Niche(s) c-7 5 h
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:
Corner Markers (set of 4 $20) Opening Closing W 0 H
Circle One
Vase and Ring for Niches (cost) 2 &J 0 0 Interment Disinterment
Temporary Marker Preparation Installation
City of Sebastian
)1(c 1,1;
TOTAL G 2 i 271 606, OD
The following documents were provided as Proof of
Residency:
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