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Certificafe No. 2325
��� �� ���������
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Wendy Micciche
147 Filbert Street
Sebastian, FL 32958
In and for consideration of the sum of $2000.00 is entitled to full interment
rights in the Sebastian Municipal Cemetery for the following lots:
Unit 4, Block 5, Lots 7& 8
of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and
regulations prescribed therefore by the City of Sebastian.
CONVEYED THIS 12t" day of March, 2012.
CITY OF SEBASTIAN, FLORIDA
►
'�AI Minner
City Manager
ATfEST:
: ' s�� �
Sally �,OMaio, MMC
�ity Clerk
UiY pF
x� s�t�� �� f
� ���.�. �' �'�,-,�.��-�;;��;
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h1011tIE L3F F�i.ICAN fSiAiNI?
City of Sebastian Municipal Cemetery Purchase Receipt
To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate
regulations, proof of City residency of purchaser or person for whom lot is intended for interment must
be provided at time of purchase.
�e �1 C� �( �l i GC i C F� �
Name(s)
I�E ��F� I b�rf S-f�reef Sef��S ti�.� �c- 3Zq5�
Address
?�7Z)_�ZI - ��
Area Code & Phone umber
Name & Residence Address of Intended Occupant if Other Than Purchaser
OFFICE USE ONLY
Receipt is acknowledged in the sum of:
�b �;lf�,g.t,�,C�Q,,h,D� �;[ /'�p-� Dollars ($ ZC7C�b . �' ° )
on this. day of
Cemetery Lot(s) and/or Niche(s).
20 for the purchase of the following described
Unit , Block `� , Lot(s) � �' � Niche(s)
�,�,�5 6j Q,v� �i -kj q D i n Lo f�' ?
for use in accordance witt�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-$20) Opening & Closing
Vase and Ring for Niches (cost)
Temporary Marker Preparation & Installation
� �
Signature of P aser
I:\1N1/1[-pATA\MS-Cg�pgtg�r\R F C F � pT_ ti p�
Interment
/W O H
Circle One
Disinterment
-1 V�ln'1L .D � ` V v . � D
� '
ty of Sebastian
The following documents were provided as Proof of
Residency:
��J�rve� 1.��e��
��er�
���
O
IFLORID�P�AR7`MENT OF State of Flori�a, Departmer�t of Health, Vital Statistics
� ���� APPLICATION FOR BURIAL - i'RANSIT PERMI7'
A. (TYPE)
1. Name of First Middle Last Date
Deceased of
PL�UL JOSEPH I�iICCICHE Death
2. Piace of Death City, Town or Location Name of (If neither, give street address)
County INDIAN RIVER SEBASTIAN Hosp. or 147 FILBERT STREET
Inst.
Month Day Year
MARCH 10, 2012
3. Name of Medical Address Phone Number
Certifier 1"fICHAEL VENAZIO, iK.D. 8005 BAY STREET, SUITE 1
Medicai Examiner X Physician SEBASTIAN, FLORIDA 32958 772-38$-2110
4. Name of Fur�eral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone IJo. (A�ea Code)
Establishment SEAWINDS FiTNERAL 735 FLEMING STREET
HOiiKEE & CREMATORY SEBASTIAN, FLORIDA 32958 41682 772-5$9-1933
5. Ct�eck a. � The medical certification has been compi�ted and signed. A completed certifiicate of death accornpanies this
Appropriate application.
Box
6. Funerai Director/
Qirect �isaeser
�.
c
�. �] �ICHAEL VENAZiO, M.D, was contacted on 3/12/2012
He/she verified that this death N✓as from natural causes, that there was no accidert nor other external cause of deafh,
and that will complete and sign the medical
certification of cause of death within 72 hours.
�',
Permission is hereby �ranted ta d
� F� fiue (5) day extension of tim�
bee�� contacted by the fiuneral (rE
72 hours.
� No extension of time for filing t e
Registrar or
Subregistrar Signature
Approvai Nurriber:
certification of
was cantacted on
of death within 72 hours.
F.E. No./Reg. No.
�lIR1AL -1'RAPI�IT PEROVII�'
He/she verifiec� that
, Medical Examiner, wii! complete and sign the
Date Signed
� of this body. Permit No. 12-41682-049
ng the death certificate (exclusive of weekends) has been requested and granted since the physician has
nd will not be able to compiete the medical certification of cause-of-death section of the death certificate within
certificate,�as been requested.
Date Date Certificate
Issued: 3/10/12 Due: 3/22/2012
� ��
OFiIZATION for CREMA�'!OlJ, DISS�CTfOfV, or BURIAL-AT-SEA
Date
Medicai Examiner, , gave authorization by telephone to
Funerai Director/Direct Disposer. Date
The Medical Examiner's �pproval must be obtained before disposai by any of the above methods. A waiting period of 48 hours after death is
required for all cremations.
D.
Method of Disposition:
�BURIAL
❑CREMATION
Signature of Sexton
or Person-in-Charge
� STORAGE
�OTHER (Specify)
} _ ,�.� � - �
CEl1lIETERY OR C�iEM/�TORY � ��
Place of Disposition S,�`,B�S�i �, � ,�,i/ / ,� �/
Date of Disposition �,��� .
�
� � ��� �.ICI l lflt IIIUJI UC CI IUUfJCU U�( UIC JCJCLUII UI �,C��u��-�n-cna�ye �ur uy �ne runerai virectonuirect uisposer wnen cnere is no sexton� ana retumea
within 1d days to the local County Health Department in the county where disposition occurred.
Distribution: White: Cemetery or Crematory
DH 326, 8197 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Numbar: 5740-000-0326-2) Pink: Local f2egistrar
03/12/2012 10:3@ 7722287079 COS AIR BLDG PAGE 01/01
FUNERAL DIRECTOR'S REQUEST TO CITY OF SE8A3TIAN
FOR BURIAL OP�NING IN SE9ASTIAN MUNICIPAL CEMETERY
. �E �B�T�+4f1�
MOMIF 0� OtIICnN ISIANO
Far information contact:
Kip Kelso - Cemetery Sexton
Sebastian Municipal Cemetery
{772) 589-2545
City CIeNc's �c,�e
City HaJl, 1226 Mein Street
Sebasfian, FL 32958
O�ce (772) 388-$215 or 388-8294
Fex: (772) 589-5570
FUNER,4L HOME: __ �„
ADURESS: �� � -
�e
PHONE #: '�-�-'l -_ . _ ' -
(Check One) �
�OPEN BURIAL LOT. Lat �� 8lock _� Unit ��
OPEN CREMAINS LOT L.ot Block Unit
OPEN COLUMBARIUM N1CME Niche � Block � Unit ��
N S E IN
BURiAL DATE ANO SERVICE TIME: j(��-� r �,`� �_ bS
FOR D�CEASED: �Qc„) t � � c:,C �c�
Name
NAME AND SfGNATURE OF LQT OWNER OR REPR ENTATIVE:
(Must provide proper documentation of owners '
11 ��(� �- , 3 � l tlt`L
Name Si t Date `—'
I certify that I have determined the ownership of the above described site, that alI site fees and
administrative fees have been paid and authorize opening of same.
NAM AND SIGN TURE OF L CENSED FUN RAL DIRECTOR:
{ ' I. fYi � � � ("L�c,
Name gnature Date "'
Cemetery Sexton Certiflcat(on: ��--�--��---�--����.�����--- -�.�"��_�'
I certify that I have checked the ownership information by viewing the owner's deed and con�rming
with Cler 's office and th t a ees have been paid:
Cernet ry Se on Dat`
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.
PAULJOSEPH MICCICHE
Paul Joseph Micciche, 47, of Sebastian, FL died Saturday, March 10, 2012 at his home.
Mr. Micciche was born February 17, 1965 in Malden, MA and moved to Sebastian seven
years ago from Nashua, NH.
A graduate of Middlesex Community College in Bedford, MA, he had been an engineer
for Extreme Systems specializing in electronics and communications. He was a 4th
Degree Black Belt in the Nick Cerio Kempo style and was a member of St. Sebastian
Catholic Church.
Survivors include his wife of 25 years Wendy Legrow Micciche of Sebastian; two
daughters Andrea Micciche of Vero Beach, FL and lulie Micciche of Sebastian; parents
Joseph and Josephine Etna Micciche of Sebastian; a sister Michele Kalenoski of Nashua;
and a grandchild.