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TERMS
RATING
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CREDIT LIMIT
CITY OF SEBASTIAN
CITY CLERK'S OFFICE
REC /.
EIPT 4
Name
White - Dept of Orioin • - i
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001501322900
Garage Sales
001501341920
Copies/Bid Specs.
001501341910
LDCICode of Ordinances
001501341930
Election Qualifying Fees
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601010 343800
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001501343805
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FLORIDA DEPARTMENT OF
146x, T
A. (TYPE)
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
1. Name of First
Middle Last
Date
Month Day Year
Deceased
of
MILDRED
MARIE SHEARER
Death
SEP'T'EMBER 30, 2008
2. Place of Death City, Town or Location
Name of (if neither, give street address)
County
Hosp. or
INDIAN RIVER
V " O '-'SCR
Inst. DIXIE OARS MANOR
3. Name of Medical
Certifier �_GA-rly 5, (AR N
Address
1265 36TH STREET
Phone Number
F-IMedical Examiner
Physician
VERO BEACH, FL 32960
772 - 567 -6340
4. Name of Funeral Home /Direct Disposal
Address
Fla. Lic. No. /Reg. No.
Phone No. (Area Code)
Establishment
7303 BA3COCK STREET" SE
FOUNTAINHEAD MEMORIAL
PALM BAY, FLORIDA 32909
F041890
321 - 727 -3977
5. Check a. U The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
- b. [ 1)ft_, GARY S T :VH'.RMAN was contacted on 9/30/2008
He /she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that DR. GARY SILVERMAN will complete and sign the medical
certification of cause of death within 72 hours.
c. D was contacted on He /she verified that
, Medical Examiner, will complete and sign the
medical certification of cause of death within 72 hours.
6. Funeral Director/ ignatV16 F.E. No. /Reg. No. Date Signed
Direct Disposer F044705 10/2/2008
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. F041890- 343 -08
® 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.
Registrar or Date Date Certificate
Subregistrar Signature �` �, Issued: 10/2/08 Dye:
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 Dispositlow Place of Disposition CITY OF SEBASTIAN CEMETERY
R1 BURIAL
®CREMATION
Signature of Sexton
or Person -in- Charge
® STORAGE
DOTHER (Specify)
) — _ / -_l �0- 4i -
Date of Disposition 10/2/2008
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.
DH 326 8197 Obsoletes all previous editions Distribution: White: Cemetery or Crematory
( P ) Yellow_ Funeral Director or Direct Disposer
(Stock Number: 5740 -000- 0326 -2) Pink: Local Registrar ,�+� rpa
City of Sebastian
Sebastian Cemetery
Ph. # 1(772) 589 - 2545
Fax # 1(772)
Note This is for inrormational purposes reguarding Monuments at Sebastian Cemetery .
Note
Please return to
Dry Mix
Sebastian Cemetery
1921 North Central Ave.
Foundation poured
*k 40
32958
by : /%::6 &, *1; -� .
Attention
Cemetery Sexton
date : <ltG /I
stone installed
by ; Fountain Head
1 - 0 x 2 - 0 x
0 - 4 standard grey granite flat grass marker
date- 1 /26/10
Size :
Names & Dates:
His
Her: Mildred Shearer Branthoover
D.O.B.
D.O.B. 1915
D.O.D.
D.O.D. 2008
Legal Description
Unit :
2
Blk.:
13
Lot:
14
Approved By:
K . G . K .
K. G. K.
Checked By:
1/26/10
Date
By :
Fountain Head Memorial Park
Example
4 " deep 1211