HomeMy WebLinkAbout4-04-05CITY OF
HOME OF PELICAN ISLAND
CITY OF SEB STIAN
Unit 4, Block 4, Lot 5
Certificate No. 2274
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Jacquelyn Conner
872 Bermuda Avenue
Sebastian, FL 32958
In and for consideration of the sum of $1,000.00 is entitled to full
interment rights in the Sebastian Municipal Cemetery for the following lot:
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 12 day of November, 2010.
CITY OF SEBASTIAN, FLORIDA
I Minner
City Manager
ATTEST:
I
Name 4'A e r Ce dive,, fx /D "3 ft,e5
Unit 4/
Block
Lot 5
Date of Mark -out
Date of Burial
Name of Funeral Home
Authorized by
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KENNETH FRANKLIN "KEN"
CONNER
(November 19, 1929 November 10, 2010)
KENNETH FRANKLIN "KEN" CONNER
Mr. Kenneth Franklin "Ken" Conner, 80, died November
10, 2010 at his residence in Sebastian, FL.
He was born in Franklin County, Kansas and lived in Sebastian for 33 years
coming from Coral Springs, Florida.
Survivors include his wife of 30 years, Jackie Conner of Sebastian, FL; sons,
Michael Conner of Coral Springs, FL, Robert Conner of Parkland, FL, Douglas
Conner of West Boca, FL; daughters, Sharon Vinson of Naples, FL, Lisa
Burkhardt of Okeechobee, FL; brother, Lee Conner of Littleton, CO; sister,
Kathleen Stocks Timmerman of Strawberry Point, IA; 15 grandchildren, 6 great
grandchildren. He was preceded in death by his brother, Howard Conner.
Name of
Deceased
2. Place of Death
County
Indian River
3. Name of Medical
Certifier Michael A. Venazio
[1 Medical Examiner KA Physician
4. Name of Funeral Home /Direct Disposal
Establishment Strunk Funeral
Homes Crematory
5. Check a.
Appropriate
Box
6. Funeral Director/
itiglIMENZWAr
B.
D.
Approval Number:
Medical Examiner,
Method of Disposition:
CREMATION
Signature of Sexton
or Person -in- Charge
b. g a
c.
First
DH 326, 8/97 (Obsoletes all previous editions)
(Stock Number: 5740 -000- 0326 -2)
Kenneth
City, Town or Location
Sebastian
application.
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL TRANSIT PERMIT
Middle Last
Franklin Conner
Address
8005 83rd Avenue
Sebastian, FL 32958
Address
1623 N. Central Avenue
Sebastian, Fl 32958
The medical certification has been completed and signed. A completed certificate of death accompanies this
Paige was contacted
He /she verified that this death was from natural causes, that there was no
and that Michael A. Venazio, M.D.
certification of cause of death within 72 hours.
medical certification of cause of death within 72 hours.
Si ture
11A0 t l v .invr
Name of
Hosp. or
Inst.
(If neither, give street address)
872 Bermuda Avenue, Sebastian, FL
was contacted on
F.E. No. /Reg. No.
FO44048
BURIAL TRANSIT PERMIT
Permit No. 1228 -10 -0705
Permission is hereby granted to dispose of this body.
a 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 fihe death certificate been requested. Date Certificate
�jielirer or mil/ Date 11/15/2010
Subregistrar Signature
Issued: 11/10/2010 Due:
c. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA
Date
Date
of
Death
CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemetery
Month Day Year
11/10/2010
Phone Number
772/388 -2110
Fla. Lic. No. /Reg. No. Phone No. (Area Code)
F041870 772/589 -1000
on 11/11/2010
accident nor other external cause of death,
will complete and sign the medical
He /she verified that
Medical Examiner, will complete and sign the
Date Signed
11/11/2010
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.
Date of Disposition Saturday, November 13, 2010
BURIAL DSTORAGE
❑OTHER (Specify)
/Ke
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.
Distribution: White: Cemetery or Crematory
Yellow: Funeral Director or Direct Disposer
Pink: Local Registrar
Sep 26 2008 2:45PM
FOR DECEASED:
C ter Sexton
HP LASERJET 3200
FUNERAL DIRECT R'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
5EBAsTIAN etti
NON! U PEtKM. IfUND
For informatior contact:
Ki Kelso Cemetery Sexton
Se astian Municipal Cemetery
(772) 589 -2545
City Clerk's Office
city Hall, 1225 Main Street
Sebastian, FL 32958
OINcr (772) 388.8215 or 388 -8214
Fax: (772) 589.5570
FUNERAL HOME: 4tie
ADDRESS:
PHONE l: 77tv? (g
rvarne
ck One)
Ch 2 OPEN BURIAL LOT L t t5 Block_�/� Unit
OPEN CREh1AINS LOT L t Block Unit
OPEN COL'JMBARIUM NICHE Nliche Block Unit
BURIAL DATE AND SERVIC` TIME: i t
NAME AND SIGNATURE F LOT OW ER OR REP SENTATIVE:
(Must rovide proper do mentation of ■wnership)
/CO /Ate,'
Name Signature
This form to be provided to Clerk's Off.c
//A/0
Date
W
I certify tnat I have determined the ovine ship of the above described site that all site fees and
administrative fees have been paid and uthorize opening of same
N '1E AND SIGNAT RE OF LICE SED FUNERA
m e '1/�/L %vim D Sig naiLie at: //a
Cemetery Sexton Certification:
I certify that I have checked the ownersAp information by viewing the owner's deed and confirming
with Clerk's office end that all fees have been paid
by Sexton for perrnanert record upon completion.
//e)
Date
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