HomeMy WebLinkAbout1-28-09CITY OF
HOME OF PELICAN ISLAND
Certificate No. 2280
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:
John & /or Veronica Quinn
732 Hall Avenue
Sebastian, FL 32958
In and for consideration of the sum of $1,000.00 is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following lot:
Unit 1, Block 28, Lot 9
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 6" day of January, 2011.
CI OF SEBASTIAN, FLORIDA ATTEST:
Al Minner Sally . Maio, MMC
City Manager •City Clerk
Name V K- tic
Unit
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Date of Burial 'it� / Cl Time b OU 0 J\
Name of Funeral Home 5 !� c.J Ar -S
Authorized by
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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 of
VERONICA JANE QUINN Death FEBRUARY 23, 2011
2. Place of Death City, Town or Location Name of (If neither, give street address)
County INDIAN RIVER SEBASTIAN Hosp.or SEBASTIAN RIVER MEDICAL CENTER
Inst.
3. Name of Medical Address Phone Number
Certifier DR. MICHAEL VENAZIO 8005 BAY STREET SUITE 1 772- 388 -2110
Medical Examiner g I Physician SEBASTIAN FLORIDA 32958
4. Name of Funeral Home /Direct Disposal Address Fla. Lic. No. /Reg. No. Phone No. (Area Code)
Establishment SEAWINDS 735 SOUTH FLEMING STREET
SEBASTIAN, FLORIDA 32958 41682 772 - 589 -1933
5. Check a. F-1 The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b.] DR. MICHAEL VENAZIO was contacted on 2/24/11
He /she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that HE will complete and sign the medical
certification of cause of death within 72 hours.
C.
was contacted on
medical certification of cause of death within 72 hnurc
He /she verified that
Medical Examiner, will complete and sign the
6. Funeral Director/ nat F.E. No. /Reg. No. Date Si ned
Direct Disposer F046789 —° f
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 11- 41682 -039
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 filing the certificate has been requested.
Registrar or Date Date Certificate
Subregistrar Signature Issued: C12 Due:
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 SEBASTIAN CEMETERY
BURIAL
CREMATION
Signature of Sexton
or Person -in- Charge
STORAGE
DOTHER (Specify)
} x�) Q r
Date of Disposition FEBRUARY 28, 2011
I 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
within 10 days to the local County Health Department in the county where disposition occurred.
Distribution: White: Cemetery or Crematory
DH 326, 6/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number: 5740 - 000 - 0326 -2)
Pink: Local Registrar
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
SEeK"
VOW a PRICAN Mono
For information contact:
Kip Kelso - Cemetery Sexton
Sebastian Municipal Cemetery
(772) 589 -2545
City Clerk's Office
City Hall, 1225 Main Street
Sebastian, FL 32958
Office (772) 388 -8215 or 388 -8214
Fax: (772) 589 -5570
FUNERAL HOME:
ADDRESS:
PHONE #:
(Check One)
SJPEN BURIAL LOT Lot _Block Unit
_OPEN CREMAINS LOT Lot Block Unit
_fJPEN COLUMBARIUM NICHE Niche Block Unit
�/_ W
BURIAL DATE AND SERVICE TIME:i
FOR DECEASED: oa iG T
name
14AME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE:
(Must provide proper documentation of ownership)
Name
Signature Date
I certify that I have determined the ownership of the above described site that all site fees and
administrative fees have been paid and authorize opening of same
NAME AND SIGNATURE OF LICENSED FUNERAL DIRECTOR.
Name 'Signature Date
------------------------------------------------------------------------------------------------------------------------------
Cemetery Sexton Certification:
I certify that I have checked the ownership information by viewing the owner's deed and confirming
with Clerk's office an that all fees have been paid
Ce et ex ton Date
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.
of
SfB
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HOME Of PELICAN IRLAND
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 of purchase.
UY V uO /► i
W)ykA-imk Total Paid /000.00
Initials
White - Dept. of Origin • Yellow - Finance • Pink • Applicant
CITY OF SEBASTIAN
CITY CLERK'S OFFICE
RECEIPT
4270
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Name —J D b n
O u t ri n
❑ Cash
�—
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Check #�
Date
No.
Amount Paid
001001208001
Sales Tax
001501322900
Garage Sales
001501341920
Copies/Bid Specs.
001501341910
LDC /Code of Ordinances
001501341930
Election Qualifying Fees
/ (�
601010 343800
Cemetery Lots��
Lot/Niche (I , Block , Unit
001501343805
Cemetery Fees
W)ykA-imk Total Paid /000.00
Initials
White - Dept. of Origin • Yellow - Finance • Pink • Applicant
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