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Home My WebLink About2-46-12i i � II rtii ,a �� ti;Q i HW ¢� �!U i i i c i i 1- I /�/: (�(+T{t '. ^4' �'. i � �, � G I i � .� - - -- Sep 26 2008 2:45PM HP LASERJET 3200 p•1 i FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY E BA-ST hONt G r4lK/a.ISIAND Fo: rformst or contact: Ki Kelso - Cemd!e,y Sexton Se ystian hlz.nicipsl comefery (7 ?2) 599 -2545 I City Clerk's O`6ce oji y Flat:, 1225 Main °freet i Sabasban, FL 32958 Olh'cO (772) 388 -8215 or 3aa -9214 Fax: (772) 589.5570 FUtiERAL HOME STRUNK FUNERAL HOME & CREMATORY 1693 Nn- rentral eve- ADDRE5S PHONE 4 TIAN (Check One) 2rOPEN BURIAL LOT L� l Block Unit OPEN CREMAINS LOT L t Block Unit OPEN COL'UMBARIUM NICHE N'che Block Unit B'JR;AL DATE AND SERVICE TIME: 2 -ilffiq IV f C DECEASED: rj ft,4v-N FZFe AND SIGNATJRE OF LOT OVVi F-R REPRESENTATIVE: (Mus rw docurnental,cn of we s—c n- 2011 Name S gnature Rate I I certify :nat I have determined the owne� ship of ;he above described site lhal all site fees and Urninistrative tees have been paid and i authorize open,ng of carne - yA4IE AND SIGNATJRE OF LICENSES UNERAL DIRECTOR. i ,Name 'Signature Date ------------------------- - ...... ._- ..__. .... ............. ---------------------------------------------------- Cemetery Sexton Certlfication: 1 certify that ! have checked the ovrnersl ip information by viewing the owner's deed and conf4min, with Clerk', office and that a!I fees have been paid -- A�d 0 . 5;� - 6 X,,— Ge ter Sexton Date This form to be provided to Clerk's Off.c by Sexton for perruanert record upon complelion. I Name&lli Ye 042 1e / !K,05 A( YA/ 8 Unit Block Lot Af . Date of Mark -out `jl�T�� Date of Burial / �� Time Name of Funeral Home_ S Authorized by VII 1 Vr or 0moi imm CITY CLERK'S OFFICE 4306 RECEIPT Name Sf ru.nk /Worfhe1n ❑ Cash Date N(Check# No. Amount Paid 001001 208001 Sales Tax 001501322900 Garage Sales 001501 341920 Copies/Bid Specs. 001501341910 LDCICode of Ordinances 001501 341930 Election Qualifying Fees 601010 343800 Cemetery Lots Lot/Niche / 2, Block, Unit CZ 001501 343805 Cemetery Fees 50- _ a y w Total Paid 50• oo Initials White - Dept. of Origin • Yellow - Finance • Pink - Applicant Zy - I I t,,)uu t4nn Worlhen LV L_ M 6L i 0,5 5 +�- LL Y1,k.1 c�_ adcl- q b I --o 1/1 W J �Y%oS b -23' 1 I X50, 00 L- u Nc S 4- ry\% n i jte r { M � j Name r !} 4fit.' Unit Block Lot Date of Mark -ou #�" f ,�% � � ,fir; r°� � Date of Burial -Time Name of Funeral Home Authorized by WORTHEN, Ruth Ann 374 —A So. Wimbrow Sebastian Deed # 432 (for parents: Herman and Faye Swierkos) Block 46, lots 11 and 12, Unit 2 Addition Herman interred lot 11, 1116181 Paid by General Receipt No. Dated .... ...�R /..... . List Price $ * *200.00 * * Maximum No. Burial spaces 2 Discount $,,, "O •••••.. Total area in square feet Net Paid $.. �.G1C�, O� ................ Monument permitted ... FZ a t - -(Data above this line for City Record only) �r Deed # 432 Ruth Ann Worthen for(parents) Herman & Faye Swierkos 374 -A S. Wimbrow, Seb. Block 46, lots 11 and 12, Unit 2 Addi tion Herman interred 1116181 in lot 11 Total Paid Inkials White - Dept. of Origin • Yellow - Finance • Pink • Applicant ", &A. kA.."^� S 4. C." I Qd Pccl n r i 7l. M"; C4. A (a t e 6— A P"A CITY OF SEBASTIAN CITY CLERK'S OFFICE 3536 RECEIPT Name 4co Cash heck Date No. Amount PaW 001001208001 Sales Tax 001501322900 Garage Sales 001501341920 CopieslBld Specs. 001501341910 LDGCode of Ordinances 001501341930 Election Quardying Fees 601010 343800 Cemetery Lots Lot'Niche . Block Unit _ 001501343805 Ceme Fees e� a!"V Total Paid Inkials White - Dept. of Origin • Yellow - Finance • Pink • Applicant ", &A. kA.."^� S 4. C." I Qd Pccl n r i 7l. M"; C4. A (a t e 6— A P"A "ixf State of Florida, Department of Health, Vital Statistics APPLICATION FOR BURIAL - TRANSIT PERMIT A. (TYPE) 1. Name of First Middle Last Date Month Day Year Deceased Beuna Faye Swierkos Death Feb. 17 2006 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 War Sharar, M.D. 7754 Bay Street MMedical Examiner Physician Sebastian, FL 772 -989 -3000 4. Name of Funeral Home/ sa Address Fla. Lic. No. /Reg. No. Phone No. (Area Code) Establishment 1623 N. Central Ave. Strunk Funeral Home Sebastian;' FL 1228 772 -589 -1000 5. Check a. 0 The medical certification has been completed and signed. A completed oedificate of death accompanies this Appropriate application. Box b. 0 Pat was contacted on 2/20/06 He/she verified that this death was from natural causes, that there was no accident nor other "6Xt6nn*cause of death, and that Dr. Sharar will complete and sign; the medical certification of cause of death within 72 hours. C. was contacted on He/she verged that Medical Examiner, will complete and sign the medicyi certKesillon oyclaWWof death within 72 hours. 6. Funeral Director/ Z n ro j , E ed . No. /Reg. No. Date 2g� /06 DWEI nmst.d r B. BURIAL - TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No. 1228- 06-0084 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. rjNo extension of time for filing the death certificate has been requested. Registrar or' Date 2/17/06 Date Certificate 22 /06 Subregistrar Signature �}(, Issued: Dye: C. 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. D. CEMETERY OR CREMATORY Method of Disposition: Place of Disposition Fort Pierce Crematory BURIAL DSTORAGE Date of Disposition OCREMATION OTHER (Specify) Signature of Sexton or Person -in- Charge } ' 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 .retumed within 10 days to the local County Health Department in the county where disposition occurred. Distribution: white: Cemetery or Crematory DH 326, 8187 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer 0.1 M. (Stock Number. 5740.000-0326 -2) Pink: Local Registrar