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Certificate No. 2047
CITY OF SEBASS `f
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Fred M. Cody 444 Biscayne =Lane, Sebastian, Fl 32958
(name) (address)
in and for consideration of the sum of $700.00 is entitled to full interment rights in the
Sebastian Municipal Cemetery for the following plot:
Unit —1— Block 29 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 26th day of September, 2005.
CITY F S STIAN, FLORIDA AT T:
1 inner y Maio, MMC
i Manager City Clerk
O O
Name _/ A C 4) ivc - t C).4) ,
Unit
Block
Lot
Date of Mark-out �J�!
Date of Burial- Time
iI. re, w
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Name of Funeral Home s ` U i 1
Authorized by
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FLORIDA DEPARTMENT OF
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A. (TYPE)
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
1. Name of
First
Middle Last
Date
Month Day Year
Deceased
Fred
M. Cody
of
February 22, 2012
Death
2. Place of Death
City, Town or Location
Name of (If neither, give street address)
County
Indian River
Sebastian
Hosp. or 444 Biscayne Lane
Inst.
1 Name of Medical
Taher Husainy M.D.
Address
Phone Number
Certifier
787 37th Street Suite E210 Vero Beach, Florida 32960
(772) 770 -0808
Medical Examiner
hysician
4. Name of Funeral Home /Direct Disposal
Address
Fla. Lic. No. /Reg. No.
Phone No. (Area Code)
Establishment
Strunk Funeral Home
1623 North Central Avenue Sebastian,
F041870
(772) 589 -1000
and Crematory
Florida 32958
5. Check a. LJ The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box 2 �012-
b was contacted on 2Z 1
He /she verified that this deatmlom natural causes, that there vas no accident nor other external cause of death,
and that will complete and sign the medical
certification of cause of death within 72 hours.
C. was contacted on He /she verified that
, Medical Examiner, will complete and sign the
medical certification of cause of death within 72 hours.
6. Funeral Director/ / Si turd " r F.E. Reg. No. �at� Sign df
F04242 972
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228 -12 -90
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 death#iF �en requested.
RPnior Date Date Certificate
Subregistrar Signature issued: 2/22/012 Due: 2/27/2012
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 S
n
URIAL STORAGE Date of Disposition ;ZA j?//x
❑CREMATION OTHER (Specify)
Signature of Sexton
or Person -in- Charge
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.
DH 326, 8197 (Obsoletes all previous editions)
(Stock Number: 5740- 000 - 0326 -2)
Distribution: White: Cemetery or Crematory
Yellow: Funeral Director or Direct Disposer
Pink: Local Registrar
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
(no
How (* puxm KIATO
For information contact:
Mp 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: STRUNK FUNERAL HOME & CREMATORY
1623 No. Centrat Ave.
ADDRESS: SEB11511AN, FL 32958
PHONE #: (7723 589.1000
(Check One)
ii OPEN BURIAL LOT
OPEN CREMAINS LOT
OPEN COLUMBARIUM NICHE
BURIAL DATE AND SERVICE TIME:
FOR DECEASED: 0
O
Name
Lot L-- Block Z-a Unit
Lot Block Unit
Niche Block Unit
a a�'"ro:
Cddu
NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE:
(Must provide proper documentation of ownership)
Name
�Saii re 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:
On I k4i 1 �%u r� l � � S LAV 21,)
_41(2-
Name ignature 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 and that all fees have been paid:
CemetAry Axfo n Date
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.
1225 Main Street, Sebastian, F132958
Telephone (772) 589 -5330 — Fax (772) 589 -5570
September 27, 2005
Mr. Fred M. Cody
444 Biscayne Lane
Sebastian, Fl 32958
Dear Mr. Cody:
Enclosed is City of Sebastian Certificate 2047 entitling you to full interment rights in Cemetery
Lot 4, Block 29, Unit 1. Also enclosed is a copy of the Rules and Regulations governing the
Sebastian Municipal Cemetery.
If you have any questions, please contact our office.
Si ere y,
Sally Mai C
City Clerk
SAM:ar
enclosure
M or
SEISASTKN
y.
HOME OF PELICAN ISLAND
City of Sebastian Municipal Cemetery
Purchase Receipt
T
To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery
rate regulations, residence of purchaser or person for whom lot is intended for interment must be
provided at time of purchase
Na
s Gr91liL1�
Address
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Recei t is acknowledged in the sum of:
Dollars ($ JJd . ° `r )
on this � 5� �W day of , 20 —e-5-for the purchase of the following
described Cemetery Lot(s) a %or Niche(s).
Unit_, Block, Lots) Niche(s)
for use in accordance with the conditions, ordinances, resolutions, rules and regulations
prescribed therefore by the City of Sebastian.
Additional Fees paid at time of purchase:
Corner Markers (set of 4 - $20) Opening & Closing
Vase and Ring for Niches (cost)
Interment / Disinterment
ity of Sebastian
Service tees are to be paid at time of need only
1: \W W- DATA \Ms - Cemetery\RECE I PT.doc
W O H
Circle One
7� d. ef;�)
FRED M. CODY
PETROLEUM ENGINEER
444 BISCAYNE LANE PH. 772- 589 -6284 63-1383/670 24014894 7539
SEBASTIAN, FL 32958
PAY TO THE DATE
ORDER OF
i s 700
a: • DOLLARS 8
':Cos one
SeDeellen, Fbritle 32958
,-888.883 -8452
MEMO
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