HomeMy WebLinkAbout4-05-03QIY OF
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H4ME OF PELICAN ISLAND
Certificate No. 2314
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Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Bernard McLaughlin
967 Dolphin 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 4, Block 5, Lot 3
of the Sebastian Municipal Cemetery,
as maintained on file in the records of #he City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and
regulations prescribed therefore by the City of Sebastian.
CONVEYED THIS 9th day of ]anuary, 2012.
CITY OF SEBASTIAN, FLORIDA
,
AI Minner
City Manager
ATTEST:
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Sally . Maio, MMC
City Clerk
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Date of Burial
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KATHLEEN McLAUGHLIN
Born - Sunday January 18th 1925
Passed Away - Thursday December 29th 2011
Kathleen McLaughlin, 86, of Sebastian, passed away on Thursday, December
29, 2011, at home. She was born January 18, 1925 in Philadelphia, PA, and
moved to Sebastian 3 years ago from Vancouver, WA. Kathleen worked as a
Printer with the US Federal Government. She is survived by her son Bernard
"Mickey" McLaughlin of Sebastian, four grandchildren, 6 great grandchildren,
sister Virginia Prince of California, and finro brothers, Bill McCready and John van
Holle, both of Delaware. She was predeceased by her husband Bernard
McLaughlin, Sr.
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FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
� SE� .
nant a rttKru+nw+o
For information contact:
Kip Kelso - Cemetery Sexton
Se�astian MunicipaJ Cemetery
(772) 589-2545
City Clerk's Oflice
City Hall, 1225 Mafn Street
Sebastian, FL 32958
Of�ice (T72J 388-8215 or 388-8214
Fax: (772) 589-5570
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FUNERAL HOME: S,E'�� ,�� 5 ���„r,,�,,e,�� ���
ADDRESS: 7,3 � f'� e� � yCj S l
PHONE #: i C77 Z) s" 8 9-. /4 3�. -
(Che ne)
PEN BURIAI LOT Lot c3 ° Block j Unit _ �!
_�PEN CREMAINS LOT Lot Block Unit
�PEN COLUMBARIUM NICHE Niclie 6fock Unit
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BUR)A� DATE AND SERVICE TIME: / /x /� ; oa�,
FOR D�CEASED: �T��,!,�,rl ,�j , �(���zG Q,��,,�
ivame
tJAME AND SIGNATURE OF L07 OWNER OR REPRESENTATIVE:
(Must provide proper documentatior� of ownership)
Name ��/� Signature Date
I certify that I have de►ermined the ownership of the above described site that aN site fees and
administrative fees have been paid and authorize opening of same
NAME AND SIGNATURE OF LICENSED FUNERAL DIREC7GR.
Name----�- -- �----------------------------------Signature--------------------------------------- Date--------
Cemetery Sexton Certification:
1 certify thal I have checked the ownership informat�on by viewing the owner's deed and confirming
with Clerk's office �ind that all fees have been pa�d
�,� v� . �/y � .
Cemktery xton Date
This foriTi to be provided to Clerk's Oifice by Sexton for permanent record upon complet�on.
,.
'' T State of Florida, Department of Health, Vital Statistics
HEALT APPUCATION FOR BURIAL - TRANSIT PERMIT
A• (TYPE)
1. Name of First Middle Last
Deceased Date Month Day Year
Kathleen D. McLaughlin °f December 29, 2011
Death
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp, or
Indian River Sebastian Inst. 967 Dolphin Avenue I
3. Name of Medical Address '
Certifier Ralph Geiger, MD 13838 US Hwy. 1 PhoneNumber '
Medical Examiner X Physician Sebastian, FL 32958 772-581 —6900
4. Name of Funeral Home/Direct Disposal Address
Establishment Seawinds 735 Fleming St. Fla. Lic. No./Reg. No. Phone No. (Area Code)
Funeral Home Sebastian, FL 32958 F041682 772-589-1833
5. Chack a. � The medical certification has been compl�ted and signed. A completed certificate of death accompanies this
Appropriate application.
Box
6. Funeral Director/
Direct Disposer
B.
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c. �
_ Dr'. Geiaer wascontactedon 12-29-11
He/she venfiied that this death was from natural causes, that there was no accident nor other external cause of death,
and that he wili complete and sign the medical
certification of cause of death within 72 hours.
was contacted on
medical certification of cause of death within 72 hours.
«i ture F.E. No./Reg. No.
_ F046789
He/she verified that
, Medical Examiner, wiil complete and sign the
Date
�d '/
BURIAL - TRAPISIT PERMIT
Permission is hereby granted io dispose of this body.
Permit No. 1 1-41 682-252
�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 fiuneral director and wili not be able to complete fhe medical certification of cause-of-death section of the death certificate within
72 hours.
❑ No extension of time for filing the eath ertificate has been requested.
Registrar or Date
Date Certificate
Subregistrar Signature Issued:
�rr�' �°�� Due: 1-10-12
Approval Nurriber:
for CREMATION, DISSECTION, or BURIAL-AT-SEA
Date
Medical Examiner, , gave authorization by telephone to
Funeral Director/Direct Disposer. Date
The Medical Examiner's approvai 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
����X
Signature of Se�on
or Person-in-Charge
�STORAGE
�OTHER (Specify)
J 1! -�C/ �-�l -
CEMETERY OR CREMATORY SEBASTIAN CEMETERY
Place of Disposition � „��
Date of Disposition January 4, 201 2
�
� nis permit must be endorsed by the Sexton or person-in-charge (or by the Funeral DirectodDirect Disposer when there is no Sexton) and returned
�vithin 10 days to the local County Health Department in the county where disposition occurred.
)H 326, 8/97 (Obsoletes ail previous editions)
Stock Number: 5740-000.0326-2)
Distribution: White: Cemetery or Crematory
Yellow: Funeral Director or Dired Disposer
Pink: Local Registrar