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Paid b
Y CEMETERY Receipt No. , , 384 ..... 10 _ _ __
List Price $,•••450 :00 ••••Dated,,,,~s/84 ••.•••-
Net Paid $ ... ,450:00 • .... , Maximum No. Purial Spaces .....? .......... NO.
Monument Pe1mitted , , , , F'1 a t
' Lots 1 & 2, Block 37 ~••"" •••••••.. Melvin
Unit 2 Barnes ~ 1 ~F
3715 Church St.
-- (Data above mis line for City ~o~ only) Mi cco
Florida
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2'HE SEBASTZ~AN CEMETERY
City of Sebastian
Sebastian, Florida
RECEIPT IS HEREBY ACKNOWLEDGED OF THE SUM OF:
~ ~~ ~~
FROM:
Dollars ($ ~ S ~J c7~ )
oY~JiC-e' i ~ • ~ .~e
on this S ~ day of c%t. 198y for the purchase of the following
described Cemetery Lot(s) upon the terms and conditions as stated herein:
Description of Property:
Cemetery Lot(s)# ~ ~l ~ 81ock# 3 ~ Unit# -y
Purchase Price: ~`~ ~ Dollars ($ y ~ G.~ )
~-
Terms and conditions of sale:
This contract sha11 be binding upon both parties, the seller and the purchaser, when
approved by the owner of the property above described.
I, or we, agree to purchase the above described property on the terms and conditions
stated in the foregoing instrument:
The City of Sebastian agrees to se11 the above mentioned property to the above Warned
purchaser(s) on the terms and conditions stated in the above instrument.
City of S bas ian
Witness
STATE OF FLORIDA
~PARTMENT OF HEALTH & REHABILIT~E SERVICES I
VITAL STATISTICS ./ }~i
APPLICATION FOR BURIAL-TRANSIT PERNiIT u~ t . ~('
r ~ bl~
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased O F
Helen Jewel Barnes DEATH Aug. 1, 1984
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Roseland Inst. HUMANA HOSPITAL SEBASTIAN
3. Name of Medical [~'hysician Address
Certifier Farhat Khawa ja, M.D ^ Medical Examiner Bay St . Plaza Bay St . Roseland, Fla .
4. Funeral Home/ Name Address
cD1~Pottinger & Son Funeral Home 1200 S. Indian River Dr. Sebastian Fla. 32958
5. Check a ~ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b ^ was contacted on . He/she verified that
Box this death was from natural causes, that there was no accident nor other external cause of death, and that
will complete and sign the medical certification of
cause of death.
c ^ was contacted on . He/she verified that
Medical Examiner, will complete and sign the
P n~ic~J certification.
6. Funeral Di
ature
2368
Fla. Lic. No./Reg. No.
August 2, 1984
Date Signed
B. BURIAL-TRANSIT PERMIT
Permit No. 759-560
Permission is hereby granted to dispose of this body.
^ A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and
granted. If it cannot be filed within this time limit, a "Funeral Director/Direct Disposer Report" will be filed
with the Local Registrar of the County in which death occurred.
Registrar or rsf- ~ Date J~~~~ j, /G~r
Sub-Registrar Signature lli~ Issued
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL-AT-SEA
Signature
or
Medical Examiner 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:
BURIAL ^ STORAGE
^ CREMATION ^ OTHER (Specify)
Signature of Sexton 1 Deborah C.
or Person-in-~ti 'qe ,
This permit must be endorsed by the Sexton or person-in-charge (o~ 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.
ty lerk
Sebastian Cemetery
Place of Disposition Sebastian Florida
Date of Disposition August 4, 1984
HRS Form 326, APR. 81
(replaces previous editions which may be used.)