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Certificate No. 2275
CITY OF SEBASTIAN
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Alice Giordano
4065 9t" Place
Vero Beach, FL 32960
In and for consideration of the sum of $2,000.00 is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following lot:
Unit 4, Block 4, Lot 32
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 17 day of November, 2010.
CITY OF SEBASTIAN, FLORIDA
ATTEST:
Sally A aio, MMC
City Clerk
Name /A? C /A[ r (T• 9 it) L 4 i/ 9)( ID 3 if S
Unit
Block
Lot
Date of Mark -out //7/
Date of Burial
r
Name of Funeral Home S u
Authorized by 4 AlVtLitt Win A A
Time
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C.
D.
FLORIDA DEPARTMENT OF
HEALT
A. (TYPE)
Name of
Deceased
2. Place of Death
County
Charlotte
3. Name of Medical
Certifier San eev Zutshi
Medical Examiner Physician
4. Name of Funeral Home /Direct Disposal
Establishment Strunk Funeral
Homes Crematory
5. Check a.
Appropriate
Box
6. Funeral Director/
B.
Approval Number:
Medical Examiner,
1
DH 326, 8/97 (Obsoletes all previous editions)
(Stock Number: 5740 -000- 0326 -2)
Vincent
First
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL TRANSIT PERMIT
City, Town or Location
Port Charlotte
Middle Last
J. Giordano
Address
3390 Tamiami Trail Suite 105
Port Charlotte, Florida 33952
Address
1623 N. Central Avenue
Sebastian, Fl 32958
The medical certification has been completed and signed. A completed certificate of death accompanies this
application.
Kelly was contacted on 11/11/2010
He /she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Sanjeev Zutshi. M.D.
certification of cause of death within 72 hours.
medical certification of cause of death within 72 hours.
BURIAL TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228 -10 -0707
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 filin eath certificate has been quested.
Iilogiarrg or Date 11/11/2010 Date Certifirte/ 16 /2010
Subregistrar Signature Issued: Due:
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.
Method of Disposition:
BURIAL ['STORAGE
['CREMATION OTHER (Specify)
Signature in of Sexton �%�fJ
or Person -in- Charge J
Name of (If neither, give street address)
Hosp. or
Inst. Peace River Regional Medical Center
Date of Disposition
Fla. Lic. No. /Reg. No.
FO41870
AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA
Date
gave authorization by telephone to
Date Month Day Year
of
Death 11/11/2010
Phone Number
941/883 -5050
Phone No. (Area Code)
772/589 -1000
Distribution: White: Cemetery or Crematory
Yellow: Funeral Director or Direct Disposer
Pink: Local Registrar
will complete and sign the medical
was contacted on He /she verified that
Medical Examiner, will complete and sign the
F.E. No. /Reg. No. Date Signed
F044048 11/11/2010
CEMETERY OR CREMATORY
Place of Disposition SG ,37 (.?e-
yy
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.
Sep 26 2008 2:45PM
FUNERAL HOME:
ADDRESS:
PHONE
HP LASERJET 3200
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENI G IN SEBASTIAN MUNICIPAL CEMETERY
SE
now, u PL C .k isuwo
For informatior. contact:
Ki Kei;o Cemetery Sexton
Se astian Municipal Cemetery
r (772) 589 -2545
City Clerks Office
ity Halt, 1225 Main 8freet
Sebastian, FL 32958
0111 (772) 398 -8215 or 388.8214
Fax: (772) 589.5570
POP
1 23 No. Central Ave.
I IAN, 3zyJi
(Chef One
V OPEN LOT Lot .3� Block
Unit
OPEN CREMAINS LOT Lot Biock Unit
OPEN COLUMBARIUM NICHE Niche Block Unit
BURIAL DATE AND SERVICE TIME:
FOR DECEASED:
!vane
NAME AND SIGNATURE F LOT OW ER OR REPRESEVTATI
(Mu rovide proper do mentation of •wnership)
(Mu
A
Narne
Date
I certify tnat I have determined the owne ship of the above described site Ihat all site fees and
administrative fees have been paid and uthorize opening of sa e
Signature
NAME AND SIGNAT E OF LICENSED FUNERA; i R
Name
This form to be provided to Clerk's Off.c
by Sexton for perrnanert record upon completion.
Date
Cemetery Sexton Certification:
1 certify that I have checked the owners ip information by viewing the owner's deed and confirming
with Clerk's office and that all fees have een paid
a t e //r/t)
p. 1