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CRY Of
SEBASTIAN
HOME OF PELICAN ISLAND
Certificate No. 1993
CITY OF SEBASTIAN
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Samuel F. and/or Marian I. Harman P. 0. Box 780537, Sebastian, Fl 32978
(name) (address)
in and for consideration of the sum of $700.00 has purchased and is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following plot:
Unit 1_Block 29 Niche 11
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 18th day of November, 2004.
" Y OF SEB: o , FLORIDA ATTEST:
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f jc1( e'er ),7 _
Terren.c- ' . Moore Sall A. Maio, CMC
City Manager City Clerk
(CY
CITY OF SEBASTIAN
CITY CLERK'S OFFICE 3 1 7 3
RECEIPT
Name/,, //✓ ■-5-- f7/� Zm'9� ❑ Cash
Date /�f O� eckif,8G8
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 7•0 0.ea
Lot/Niche�1 ,Block WY Unit
001501 343805 Cemetery Fees 00
•,v;I Total Paid 775;614
In als (FM
White gin• Yellow-Finance •Pink•Applicant
CfiY OF
SLDASTIAN
HOME OF PELICAN ISLAND
1225 Main Street, Sebastian, Fl 32958
Telephone (772) 589-5330—Fax (772) 589-5570
November 18, 2004
Mrs. Marian S. Harman
P O Box 780537
Sebastian,Fl 32978
Dear Mrs. Harman:
Enclosed is City of Sebastian Certificate 1993 for the purchase of Cemetery Lot 11, Block 29,
Unit 1. Also enclosed is a copy of your receipt and the Rules and Regulations governing the
Sebastian Municipal Cemetery.
If you have any questions, please contact our office.
Sincergly,
Sally A. aio, CMC
City Clerk
SAM:ar
enclosure
ImO
SEBAST
HOME OF PELICAN ISLAND
City of Sebastian Municipal Cemetery
Purchase Receipt
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
1/4, 9"ef .�19, /x1" ' 1.
Name(s /
_ tge < 78'0,5-37. -'5; 9 sfrp� /L .
Address
Area Code & Phone Number
Residence Address of Intended Occupant if Other Than Purchaser
Office Use Only
Receipt is acknowledged in the sum of:
4-kJ Or/ z--- Dollars ($70�. 6 o )
on this /i.74 day of '€ 4 - , 20e, for the purchase of the following
described Cemetery Lot(s) and/or Niche(s).
Unit / , Block 17 , Lot(s) // 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 7-57 D O 0 H
Circle One
Vase and Ring for Niches (cost) Interment Disinterment
TOTAL $ 77s a O
Signature of Purchaser City of Sebastian
Service fees are to be paid at time of need only
I:\W W-DATA\Ms-Cemetery\RECEI PT.doc
FLORIDA DEPARTMENT OF / 02,7 // (1(111) •
T TE A Trr State of Florida, Department of Health,Vital Statistics
j� fl APPLICATION FOR BURIAL -TRANSIT PERMIT
A. (TYPE)
1. Name of First Middle Last Date Month Day Year
Deceased of
Samuel Francis Harman Death Nov. 12 2004
2. Place of Death City,Town or Location Name of (If neither,give street address)
County Hosp.or
Broward Fort Lauderdale Inst. Kindred Hospital
3. Name of Medical Address Phone Number
Certifier Abraham Zighelboi , M.D. 1516 East Las Olas Blvd. 954-384-9996
nMedical Examiner Physician Fort Lauderdale, FL 33301
' 4. Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
p 9
Establishment 1623 N. Central Ave.
Strunk Funeral Home Sebastian, FL 1228 772-589-1000
5. Check a. ❑ The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. ril Dr. Zighelboim was contacted on 11/12/04
He/she verified that this death was from natural causes,that there was no accident nor other external cause of death,
and that He 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
medic rtifi ••• of cause of death within 72 hours.
6. Funeral Director/ Si_ - F.E. No./Reg.No Date Signed
Direct Disposer 1862 11/12/04
B. BURIAL -TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228-04-0415
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 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.
Aegis}rarerr Date Date Certificate
Subregistrar Signature Issued: 11/12/04 Due: 11/17/04.9 .
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 Sebastian Cemetery
BURIAL ❑STORAGE Date of Disposition i7/�& A 7 .
CREMATION MOTHER(Specify)
Signature of Sexton
or Person-in-Charge } x� ��
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. - f
Distribution. White' Cemetery or Crematory
DH 326,8/97(Obsoletes all previous editions) Yellow: Funeral Director or Direct Dispose r
'Stock Number 5740-000-0326-2) Pink: Local Registrar �` r( ,`j
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