HomeMy WebLinkAbout1-02-07��
_ . • . . � �v�C� �`. � �- �
�AIN FAMILY - �
C/0 LORITA CAIN FLYNT
" 118 HIALEAH AVENUE
FORT PIERCE, FLA. �`����b �I,����
'� �
aC S � ' �`r' � 4 Ga� �
ENTIRE BLOCK #2 UNTI #1 �.u0 1� � ��u,�b''
BELONGS T0: CAIN FAMILY
SEE ATTACHED DRAWING
AFTER A THOROUGH INVESTIGATION OF PROPER
OWNERSHIP, MS.;LORITA CAIN FLYNT WAS _
NOTIFIED OF OWNERSHIP ON 10/19/83. -
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Harney C. Cain Jr.
August 09, 1923 - November 13, 2011
Harney C. Cain Jr. 88, of Fort Pierce, FL passed away November 13, 2011 at his
residence. Mr. Cain was born in Fort Pierce, F� and a lifetime resident. He was the
former owner of Sunrise Tractar Campany of Fort Pierce and a veteran of the United
States Navy serving in WWII.
Survivors include his Niece Allyson Flynt McFauls af Jacksonville, FL.
He is preceded in death by his parents Harney and Mattie Cain, sister Lorita Cain
Flynt.
.�t,c.i�t G�-(
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FUNERAL OIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
� �� � .
HOME O� VFIKAN iStANO
For information coniact:
Kip Kelso - Cemetery Sexton
Sebastian Municipa! Cemetery
(772) 589-2545
City Clerk's Office
City Hall, 1225 Main Street
Sebastian; FL 32958
Office (772) 388-8215 or 388-&214
Fax: (772) 589-5570
FUNERAI HOME:
ADDRESS' / 1101 South U.S. Hwy 1, Fort Pierce, FL 34950
PHONE #: (772) 461-7000 _
(Che ne)
PEN BURIAL LOT Lot �_Block _�Unit /
��PEN CREMAINS LOT Lot Block Unit
_�PEN COLUMBARIUM NICHE Niche ' Block Unit
� � W
BURIAL DATE AND SERVICE TIME: _�����j �: o
FOR DECEASED: � �,,�G �i �,�,,,� � � .
ivame
NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE:
(Must provide pro er documentatior� of ownership)
►vame Signature Date
I certify that I have determined the ownership of the above described sile that all site fees and
administrative fees have been paid and authorize opening of same
NA��1E AND SIGNATURE OF LICENSED FUNERAL DIREC7GR.
,� sl ii
tvame Signat�tre Date
Cemetery Sexton Certification:
I certify that I have checked the ownership infor�r�at�on by viewing the owner's deed and confirming
with Clerk's office �3nd that all fees have been pa�d
• l/ � //
Ce etery exton Dace
This fonT� to be provided to Clerk's OfFi�e by Sexton for permanent record upvn complet�on.
State of Florida, Department of Health, Vital Statistics
HEALT APPLICATION FOR BURIAL - TRANSIT PERMIT
A. (TYPE)
1. Name of First Middle Last Date Month Day Year
Deceased Harney C. Cain Jr. �f November 13, 2011
Death
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Saint Lucie Fort Pierce Hosp. or 1802 Paseo Ave
Inst.
3. Name of Medical Address Phone Number
Certifier
David Fromang M.D. 1912 Nebraska Ave
Medical Examiner Physician
Fort Pierce, FL 34950 772-466-2700
4. Name of Funeral Home/Direct Disposal Address 1101 South US Hwy �� l Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment
Yates Funeral Home & Crematory Fort Pierce, FL F048144 772-461-7000
5. Check a. � The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
6. Funeral Director/
Direct Disooser
B.
c.
�
b• ❑ 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 will complete and sign the medical
certification of cause of death within 72 hours.
�• ❑ was contacted on He/she verified that
, Medical Examiner, wili complete and sign the
medical certification of cause of death within 72 hours.
F,E. No./Reg. No. Date Signed
F044932 11/I6/11
BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 48144-167-11
� 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.
nNo extension of time for filing the death certificate has been requested.
_�.
Registrar or ; s� Date Date Certificate
Subregistrar Signature ,��... ���, ��p,,, �� Issued: 11 / 16/ 11 Due: 11 /26/ 11
�
Approval Number:
AUTHORIZATION for CREMATION, DISSECTION, or BIJRIAL-AT-SEA
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.
Method of Disposition:
�BURIAL
�CREMATION
Signature of Se�on
or Person-in-Charge
�STORAGE
�OTHER (Specify)
J _ �-�,� �
CEMETERY OR CREMATORY
Place of Disposition Sebastian City Cemetery
Date of Disposition /l �{z�/
�
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.
Distribution: White: Cemetery or Crematory
DH 326, 8/97 (Obsoletes all previous editions) Yellow: Funeral Director ur Direct Disposer
(Stock Number: 5740-000-0326-2)
Pink: Local Registrar