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Certificate No. 2072
�, I�' � �' �� $� �S. aT��,�; �T
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Jerri & Richard E. Prena 317 Fordham Street, Sebastian, Fl 32958
(name) (address)
in and for considera.tion of the sum of 1$ .400.00 is entitled to full interment rights in
the Sebastian Municipal Cemetery for the following plot/niche:
Unit 4_ Block _16_ Lot(s)Niche(s) 23 & 24_
of the Sebastian Municipal Cemetery,
as maintained on fde 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 22"d day of Mazch 2006.
OF SE�STIAN, FLORIDA
,
Manager
ly Maio, h
City Clerk
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Name ��--� � � �t � �},'' �' � a � l�" � I� � -
Unit r _ _ _ -
Block �� � -
�at � y - —
�����o�
Date of Mark-out —
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Date of Burial �� /�%+� ' Time !r � �� � �� � � —
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Name of Funeral H e �� f� ^'� —
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�' % i � r � �-'"';".,r-�9'..�,s.�'�.•^;,••�..d.--�
Authorized b --r —
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3,
������'ana ;
Cen" �" "� ��ess.'
She _� s ti � �r� � 15,
19Z4�` ; tt'�roqga,
Tenn., '��c�`" "moved to
Sebas�� a 25..= ,years'; ago
fTOTTi ��dTT13 t '� -, � - '
. ..r .
Legion ��liary;� both a�
Sebas�ia[ri; ; "� s�ie was +a
meinber of the Polish�'
Am,ez�cap, Club; and a for=
�ier me�ifi�i�r of tHe Vol-
� �.. s� �.. �,
�nfeer Amb�i�arice Squad
iri ��fiastian. `
., . ,
FLORIDA DEPARTMENT OF
HEALT
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State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
A. (TYPE)
1. Name of First Middle
Deceased
Jerri S .
2. Place of Death City, Town or Location
County
i ndian Itiver
3. Name of Medical
Certifier Noor ANerchant,
nMedical Examiner
�. Name of Funeral Home/BireCl'fl
Establishment
Strunk Funeral Home
5. Check a. �
Appropriate
Box
b�
�7-'
6. Funeral Gireaod
B
c. �
Last Date
of
Prena Death
e of (If neither, give street address)
i. or
Month Day Year
A�le�arch 19 2006
Sebastian inst. Sebastiar� River AAedical Center
Address . Phone Number
ii111G.D. 13060 U.S. #1
Phvsician Sebastian, FL 32958 772-589-0879
iosar� Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
1623 N . Central Ave.
Sebastian, FL 1228 772-589-1000
The medical certification has been completed and signed. A completed certificate of death accompanies tlhis
application.
�aj� was contacted on 3/30/06
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that �r. 11Aerchant will complete and sign the medical
ceRification of cause of death within 72 hours.
was contacted on
cause of death within 72 hours.
F.E. No./Reg. No.
�/%/1/I /i — 1862
BURIAL - TRANSIT PERMIT
He/she verified that
, Medical Examiner, will complete and sign the
Date Signed
3/19/06
Permission is hereby granted to dispose of this body. Permit No. 1228-06-0124
� 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 cerkificate within
72 hours.
�No extension of time for filing the death certificate has been requested.
� Date Date Certificate
SubregistrarSignature ���p Issued: 3/19/06 Dye; 3/24/06
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c. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA
Approval Number: Date
Medical Examiner, , gave authorization by telephone to
Funeral DirectoNDirect 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.
�. CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition Se�sti�r� Cemetery
�BURIAL �STORAGE Date of Disposition �j`� � /6 �
�CREMATION
Signature of Sexton
or Person-in-Charge
�OTHER (Specify)
� �
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.
DisVibution: White: Cemetery a Crematory
DH 326, 8197 (Obsoletes all previous editions) Yellow: Funeral Director or Dired Disposar
(Stodc Number. 5740-000-0326-2) Pink: Locel Registrar �� `� �