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Name
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Lot /
Date of Mark-out f 1/ / /
/- '/ •
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Date of Burial Time
Name of Funeral Home •
Authorized by
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Unit
Block /
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Date df Mark-out ., f ` 0 4)--
Date bf Burial 3 A / 5 Time
Name of Funeral Hirme _ v 3
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HOME OF PELICAN ISLAND
I
1225 MAIN STREET • SEBASTIAN, FLORIDA 32958
TELEPHONE (772) 388-8201 • FAX(772) 589-5570
September 6, 2006
TO: Kip Kelso, Sexton
FROM: Rich Stringer, City Attornly
RE: Gravesite Marker
Kip,
Lucinda McCain Macado's mother was interred with her father and, absent an official
order barring it, it is appropriate that she be allowed the placement of a marker at her
place of rest. ti
Any disputes or challenges as to the right of her mother to be there would appear to be
water under the bridge and therefore no action on those disputes is needed unless so
directed by a higher authority.
RS/sbl
FLORIDA DEPARTMENT OF ! •— ,,,_/7.
HETA
rr State of Florida, Department of Health, Vital Statistics
1`�j� 1 APPLICATION FOR BURIAL -TRANSIT PERMIT
A. (TYPE)
1. Name of First Middle Last Date Month Day Year
Deceased Helen Cula Champion Cossin McCain of February 23, 2005
Death
2. Place of Death City,Town or Location Name of (If neither, give street address)
County Hosp. or
Leon Tallahassee Inst. Capital Regional Medical Center
3. Name of Medical Address Phone Number
Certifier C.J. Bailey M.D. 1401 Centerville Road #G-02
nMedical Examiner Physician Tallahassee, Florida 32308 (850) 878-8714
4. Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No (Area Code)
Culle 's 9'
Establishment y 1737 Riggins Road
MeadowWood Funeral Home Tallahassee, Florida 32308 2
(850) 877-8191
5. Check a. ❑ The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. ❑ Dr. Bailey's office was contacted on 07/25/05
He/she verified that this death was from natural causes,that there was no accident nor other external cause of death,
and that Dr. Bailey 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 certificationpfjcause of death within 72 hours.
6. Funeral Director/ Si atur F.E.No./Reg.No Date Signed
Direct Disposer Susie Mozolic �' %�'�ryL ; //12/11774...---3299 02/25/05 Ly7
B. / BURIAL -TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No 2-7731
EA 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 certificate has been requested.
Registrar or Date Date Certificate
Subregistrar Signature r ` AA AA , '1 Issued: 02/25/05 Due: 03/08/05
C. AUTHORIZATION for CR I, •TION, 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 Sebastian Cemetery
DsKr7JRIAL ❑STORAGE Date of Disposition ,i `A /(2)
CREMATION ❑OTHER(Specify)
Signature of Sexton f/ /7
or Person-in-Charge /, ', - 4�„ b L.7
•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
vithin 10 days to the local County Health Department in the county where disposition occurred.
iH 326,8/97(Obsoletes all previous editions) Distribution: White: Cemetery or Crematory
Stock Number 5740-000-0326-2) Yellow: Funeral Director or Direct Disposer
Pink: Local Registrar
CITY OF SEBASTIAN
CITY CLERK'S OFFICE 3
RECEIPT
Name..C1ZEL, � ^ ❑ Cash
Date 7•1-(--•zt-. ,l ---_' heck
#5 t 6J 7;T
f
No. Amount Paid
001001 208001 Sales Tax
001501 322900 Garage Sales
001501 341920 Copies/Bid Specs.
001501 341910 LDC/Code of Ordinances
001501 341930 Election Qualifying Fees
601010 343800 Cemetery Lots
Lot/Niche ,Block Unit
001501 343805 Cemetery Fees cye�
/7
/7
%C1
- � - Total Paid -
Initials
White-Dept.of Origin• Yellow-Finance •Pink•Applicant