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Home My WebLink About4-05-04C7fYOF � � e i��i� � ��""�� ' ��` HOME OF PEUCAN 15LAND Certificate No. 2315 �� Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: �uana Espinoza 187 S. Mulberry Street Fellsmere, FL 32948 - 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 5, Lot 4 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 9th day of January, 2012. CITY OF SEBASTIAN, FLORIDA AI Minner City Manager ATfEST: . � �� Sally A. io, MMC City Clerk � Name /Vl�l�/A "� �n , +�� Z 'yX �D � /�ie� • Unit Biock Lot � Date of Mark-out � � z " �/u'[c' � : 3 e�O. tl�s�� Date of Burial ` / �.�� ' Time � • �� Name of Funerai Home f= a r v �''. �' S �� Authorized by , �:-,. �., :... ` 7 m N � � : i • � r� � 0 � � < m f T � r 0 ea m • � � � � v v y . y o a .. A , .� N O .� O g 0 A � O � 0 8 8 8 g S � � 3 a � �' � � g T w A � j N O� O� (O (O OC � g � p O O � � o � m � � � � N � � � � �' � �+ m -� � A � � °�` � o cci o• N EIi ,= p � �o � 7 m � � � � C ff Cy � � � � # �^ � "V � v � p � � Q O � n n � �mo m�mpp � O � T ,.,� T s mZ x � N � CIfYOF � � � �� i I i�l� � HOME C�F PEUCAN ISLAND Certificate No. 2315 �� - Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: 7uana Espinoza i �� '��f' 187 S. Mulberry Stree Fellsmere, FL 32948 - In and for consideration of the sum of $2,000.00 is entitled to full interment rights in the Sebastian Municipal Cemetery for the following lot: Unit 4, Block 5, Lot 4 of the Sebastian Municipal Cemetery, � :as maintained on file in the records of the City Clerk for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. CONVEYED THIS 9th day of January, 2012. CITY OF SEBASTIAN, FLORIDA ATTEST: AI Minner City Manager Sally A. Maio, MMC City Clerk � A. 1. Name of Deceased 2. Piace of Death County State of Florida, Department of Health, Vital Statistics APPLICATION FOR BURIAL - TRANSIT PERMIT First City, Town or Location Miami—Dade 3. Name of Medical Certifier Ta�1„q Mahmood � � �Medical Examiner� 4. Name of Funeral HomelDirect Disposal Establishment Seawinds Funeral HOme Miami Middle lu Last Date of >me z Death Month Day Year Name of (if neither, give street address) Hosp. or inst. University of Miami Hospital Phone Number 1400 NW 12th Ave. Address IFIa. Lic. No.lReg. No. jPhone No. (Area Code) 735 S. Fleming St. � 5. Chack a. � The medical certification has been compl�ted and signed. A completed certificate of death accompanies this Appropriate application. Box 6. Funera! Qirsctor/ Direct Disqoser B. c. � 2C � 2 I �. C was contacted on Helshe verified that this death was from natural causes, that there was no accident nor other ex:ernal cause of death, and that will complete and sign the medical certification of cause of death within 72 hours. � was contacted on medicaf certification of cause of death within 72 hours. re �_.... F.E. No./Reg. No. F046789 BURiAL - TRAfVSIT PERMIT He/she verified that , Medical Examiner, wiil complete and sign the Date Signed 01 /04/1 2 Permission is hereby granted te dispose of this body. Permit No. 1 2— 41 6$ 2— 0 01 ❑ A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been reques±ed and granted since the physician has been contacted by the funeral director an will not be able to complete the medical certificaiion of cause-of-death section of the death certificate within 72 hours. �No extension of time far filing the �at ertificat s been requested. Registrar or Date Date Certificate Subregistrar Signature Issued: 01 / 0 4� 1 2 Due: 01 / 1 6/ 1 2 �►U7'HORIZATION Approval Nurriber: TION, DISSECTION, or BURIAL-AT-SEA Date Medical Examiner, , gave authorization by telephone to Funeral DirectorlDirect Disposer. Date The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting period of 48 hours afiter death is required for all cremations. Method of �isposition: BURIAL �CREMATlON Signature of Sexton or Person-in-Charge ❑STORAGE �OTHER (Specity) � ,c% s�- , C�METERY OR CREMATORY Q � Place of Disposition � f� ,V d S ,4 � r� ��.�� • _ / Date of Disposition `/(o /jZ , � 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 or Direct Disposer (Stock Number: 5740-000-0326-2) Pink: Locai Registrar FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY . 5�� nOw�EOi PEtKANISW+D For information conlact: Kip Kelso - Cemetery Sexton Sebastian M��nicipa! Cemetery (772) 589-2545 City Clerk's Office City Hall, 1225 Main Street Sebastian, FL 32958 Office (T72J 388-8215 or 388-8214 Fax: (772) 589-5570 FUNERAL HOME: � �,,,�9� S ADDRESS: PHONE#: / �77'z�5 8�' /��.3 . _ (Check ne) PEN BURIAL LOT Lot � lock �' Unit 'y _,�PEN CREMAiNS LOT Lot Block Unit _�PEN COLUMBARIUM NICHE Niche 61ock Unit . "' W BURfAL DATE AND SERVICE TIME: f l'o /� �, ;apn . G�.¢c�-� l / FOR DECEASEQ: ,,.�,�,Q�� o �,�z ` i�ame I�AME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper docume�tatiori of ownership) �Y /� - Name Signature Date I ceriify 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 NAA�E AND SIGNATURE OF LICENSED FUNERAL DIREG7GFi. /✓/�• _ Name ' �Signat�rre Oate ------------------------------------------------------------------------------------------------------------------------------ Cemetery Sexton Certification: 1 certify that I have checked the ownership informat�on by viewing the owner's deed and confirming with Clerk's office and that all fees have been pa�d . / `L� Cemeter ext Date This fonT� to be provided to Clerk's Office by Sexton for permanent record upon complet�on.