HomeMy WebLinkAbout2-49-02F 9
STATE OF FLORIDA K .2A —����
GARTMENT OF HEALTH & REHABILITA* SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT
A. (Type or Print)
1. Name of
First Middle
Last
DATE Month Day Year
Deceased
OF
Fortune Edmond
Choflet
DEATH Dec. 7, 1983
2. Place of Death
City, Town or Location
Name of
(If neither, give street address)
County
Hosp. or
Indian River
Vero Beach
Inst.
Indian River Memorial Hospital
3. Name of Medical (Xfhysician Address
32960
Certifier Michael Zimmer, M.D. E] Medical Examiner 2300 5th Avenue Vero Beach Fla.
4. Funeral Home/ Name Address
[x�=yA*4= Pottinger & Son Funeral Home 1200 S. Indian River Drive Sebastian Florida 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
11 , Medical Examiner, will complete and sign the
certification.
'2368
Dec. 7, 1983
6. Ffineral Director/ X tX (1 Signature Fla. Lic. No. /Reg. No. Date Signed
B. BURIAL — TRANSIT PERMIT 759 -518
Permit No
C
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 ate ,�,�'I.�.!/!!(i�l�G� 6, � era
Sub- Registrar Signature ssued
Signature
or
AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
, 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:
U BURIAL ❑ STORAGE
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton
or Person -in- Charge
Place of Disposition Sebastian Cemetery
Date of Disposition Dec. 9, 1983
C
This permit must be endorsed by the Sexton or person -in- charge (o66y 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.
HRS Form 326, APR. 81
(replaces previous editions which may be used.)
SuHIvan, Augusta
Gale Road, Sebastian, Florida Deed #1544
Lot 2, Block 49, Unit 2 Additional
Fortune Chaflet interred 1219183
Block 49 Lot 2
Unit 2 Addnt.
Fortune Chaflet interred 1219183
Deed #/544
Augusta Sullivan
7 Gale Road
Sebastian, Florida 32958
Paid by CEMETERY Receipt No ... 3A?
••••••....Dated.. December 9., 1983
List Price $ ... 15 0. 0 0
NO' (� t a
.. 0 " Maximum No. Purial Spaces... - 1 - ll t
Net Paid $ ... 1.5 0 . 0 0 .............. .
' . Monument permitted .• Flat A u g u s t a Sullivan
7 Gale Road
Lot 2, Block 49 Unit 2 Sebastian, Florida Addnt. 329_
(Data above thh line for City Record only)
• 0
THE SEBASTIAN CEMETERY
City of Sebastian
Sebastian, Florida
RECEIPT IS HEREBY ACKNOWLEDGED OF THE SUM OF:
Dollars ($
FROM:
on this day of�4_ __, 1983 for the purchase of the following
described Cemetery Lot(s) upon the terms and conditions as stated herein:
Description of Property:
Cemetery Lot (s) N ,� B1ock(i i t# o
Purchase Price: - 15-D Dollars
Terms and'conditions of sale:
/-2
This contract shall 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 sell the above mentioned property to the above named
purchaser(s) on the terms and conditions stated in the above instrument.
City of Seb an
witness