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HomeMy WebLinkAbout4-06-01Name Uj A. U L w C L %-H- Sa (X /Z> V16 , 3df 5 Unit j Block_ Lot Date of Mark -out Date of Burial Time ^ fX Name of Funeral Home Authorized by LZ. fh a m w T IS m 6 T n R sr 'O m� CD 6] G p CD O O Z p o O C Q O O C'" C71 Ch L+ p p O G O o (D 0 O d CL C N ?` s A N I) g IS m pro c4 cD zo fa O O O O O 1° 0 1-3 R y� a v CL mr^© z Cn PS CO m -� O y T M CO j O Oo o (D 0 O d CL C N ?` w D 7 a CD R `� mQ is c 1° 0 1-3 R y� a v CL mr^© z Cn PS CO m -� O y T M CO FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY For information contact: Kip Kelso . Cemetery Sexton Sebastian Municipal Cemetery (772) 589 -2545 City Clerk's Office City Nall, 1225 Main Street Sebastian, FL 32958 Office (772) 388 -8215 or 388 -8294 Fax: (772) 589 -5570 FUNERAL HOME: Strunk Funeral Home and Crematory ADDRESS: 1623 North Central Avenue, Sebastian, Florida, 32958 PHONE #: 772 -589 -1000 (Check One) X OPEN BURIAL LOT OPEN CREMAINS LOT OPEN COLUMBARIUM NICHE BURIAL DATE AND SERVICE TIME Lot 1 Block 6 Lot Block Unit 4 Unit Niche Block Unit N S E W 4/30/2014, Wednesday 2..00 PM CHAPEL FOR DECEASED: Warren Johnson Name NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE: (Must provide proper documentation of ownership KEVIN JOHNSON fir--- -- 4/28/2014 Name ig affu 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 LIC SED FUNERAL DIRECTOR: Tim Marvin TIMOTHY W. MARVIN 4{28/2014 Name S g ature 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: :emetery Sexton Date )is form to be provided to Clerk's Office by Sexton for permanent record upon completion. State of Florida, Department of Health, Bureau of Vital Statistics BURIAL TRANSIT PERMIT HEALTH DATE PRINTED: April 28, 2014 TRACKING NUMBER: 2014062351 1. DECEDENT INFORMATION Name of Deceased Date of Death WARREN JOHNSON April 26, 2014 Place of Death - County City, Town or Location Name of facility, or street address if not a facility INDIAN RIVER SEBASTIAN SEBASTIAN RIVER MEDICAL CENTER Name and Address of Funeral HomelDirect Disposal Establishment Fla. Lic. No./Reg. No. Phone Number STRUNK FUNERAL HOME- SEBASTIAN F041870 F041870 (772) 589 -1000 1623 N CENTRAL AVE SEBASTIAN, FLORIDA, 32958 Funeral DirectorlDirect Disposer Fla. Lic. No./Reg. No. TIMOTHY W. MARVIN F022789 2. BURIAL - TRANSIT PERMIT The Florida Department of Health, Bureau of Vital Statistics hereby grants permission to dispose of this body in accordance with Chapter 382, Florida Statutes. Permit Number: 2014- F041870 -5066 Date Issued: April 28, 2014 3 Meade Grigg, State Registrar 3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL -AT -SEA, or HOSPITAL DISPOSITION Authorization given by Medical Examiner District Approval Number: 4. CEMETERY OR CREMATORY Place of Disposition: SEBASTIAN CEMETERY 0 P-0 1I Method of Disposition: BURIAL Date of Disposition: i EDRS maintains all statutorily required information regarding the death record and related burial transit permit, therefore, returning the permit to the county health department is no longer required. If the Place of Final Disposition wishes to retain the copy of the permit for their file they may do so. DH 326E, 10112 64V- 1.011, Florida Administrative Code N 0 =r 0 :3 IIJ 00 N �P Q 0 (A Ln p 0 C) N 00 Pi v (D obi � 0 CU -h m CD 0 Certificate No. 2392 Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Warren D. & Eileen T. Johnson 202 Dickens Avenue Sebastian, FL 32958 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 lots: Unit 4, Block 6, Lots 1 & 2 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 27th day of September, 2013. CITY OF SEBASTIAN, FLORIDA ATTEST: ,All Minner Sally . Maio, MMC ity Manager City Clerk r24 2011 10 ,3A ` • ti HP LASERJET FAx gik V'1 .0A go •:,.*el ''' P'\'' ,..01 5" ) li e WI, 10 lie CIO' of Sebastian SI•n,ul,rr t'rrttrrrri. Pb.h 10 7):i CIO 27+5, I'd% X II":' 12R .v92? vole : TAI,I, fnr la flrrmatlonal purpo,v, rcgnar Jlnt ttl,,nuerwati ut Sr1,;t'ii:1n ('vi is r% 'Nov r 'I'AIt It fur SI,XIc,1IsrI L r.iirldtr 211. S. torr 2 II.( r rr In h a IH,urrJ 1.,VnJ4 inn ) Ylru.r return to City of Sobadllaq `ebststlan f'onuttr% 1421 North rrnlrpl Air. } ouuJali, n I,nu r.1 3295A by T'MN/7Ti'v.r /` AIItnUun Kt p I'rntrlcrr Sexton date ^7/.��/JS I .I„u,• n,,l•rIItd V 11 YOn z _, N�ac�s r I„ ,—��r� /s:,e�w �� six. : 'f ' --„1/2..s fi5—_ Mame d D'efo KIS : w O1Z�C E LD HER ' sok) !fit 14- 2 e- E-T) ©0I\ 0,0.13. /9•Z�., 0.0.fl. _ —Y16/ i,--. Logo,Dsscrlplilon : Li Unir ; B2k, . - (,Q Lot : I Squat('FL �'— Approved By ; Ch•ckodBy : By ; Ezcnspla STRUNK FUNERAL HOME & CREMATORY 1623 No. Central Ave. SEBASTIAN, FL 32958 (772) 589-1000