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STATE OF FLORIDA A
SPARTMENT OF HEALTH & REHABILIT *E SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT
A. (Type or Print)
1. Name of
First
Middle
Last DATE Month Day Year
Deceased
OF
_ fELIX _
TERMINI DEATH Jan. 29, 1883
2. Place of Death
City, Town or Location
Name of (If neither, give street address)
County
Hosp. or
Brevard
Micco
Inst. St. Road 5, 782 Ft. South of Senne Dr.
3. Name of Medical
❑ Physician
Address Florida 32901
Certifier L. E.
McHenry, M.E. ®Medical Examiner
1350 South Hickory Street, Melbourne,
4. Funeral Home/
Name
Address
Direct Disposer
Strunk
Funeral Home, 734 North Central Avenue, Sebastian, Florida 32958
5. Check
a
The medical certification has been completed and signed. A completed certificate of death accompanies
Appro-
this application.
priate
Box
b
was contacted on . He /she verified that
6. Funeral Director/
Direct Disposer
B.
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 ® Janice at Dr. McHenry's office was contacted on 1 1 . He /she verified that
Dr. McHenry Medical Examiner, will complete and sign the
medical certification.
SignAture A Fla. Lic. No. /Reg. No. Date Signed
(J_c,, 'A . 2423 Jan. 31, 1983
BURIAL— TRANSIT PERMIT
Permit No122$'$3 -24
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 Date
Sub - Registrar Signatur _ _ - �-1 �¢�� GjL Issued January 31 , 19$3
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
A
Signature Medical Examiner Date
or
Medical Examiner, gave authorization by telephone to
Funeral Director /Direct Disposer. Date
The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting period of 48 hours after death
is required for all cremations.
Method of Disposition:
® BURIAL STORAGE
CREMATION OTHER (Specify)
Signature of Sexton
or Pt- rson -in- Charge
CEMETERY OR CREMATORY
CITY CLERK
Place of Disposition Sebastian Cemetery
Date of Disposition 2 -1 -83
.i.
This permit must be endorsed by the Sexton or person -in- charge (or by the Funeral Director /Direct Disposer when these is no Sexton)
and returned within 10 days to the local County Health Department in the County where disposition occurred.
HRS Form 320 . APR. 81
(Iej)la' t', {M editions which may be used.)
TERMINI, JEAN DEED # 514
359 MANLY AVENUE RECEIPT # 328
SEBASTIAN, FLORIDA 32958
LOT #12, BLOCK 49, UNIT #2 ADDITION
FELIX TERMINI INTERRED, LOT 12, BLOCK 49, UNIT #2 ADDN.
FEBRUARY 1, 1983
Paid by CEMETERY Receipt No. 3z$. ............ Dated ... 2 -.3 2' . .
List Price S . �$Q.•.QQ.. DEED #514
.... .. P N0.
Maximum No.
l
paces .. .�.,
Net Paid $ , 150.00 urial S • -1- • Jean Termini
Monument permitted. , Flat .. 359 Manly ..... , y Avenue
Sebastian, Fla. 32958
Receipt # 328 (Data above this line for City Record only) LOT #12, BLOCK 49
UNIT #2 ADD1
THE SEBASTIAN CEMETERY
City of Sebastian
Sebastian, Florida
RECEIPT IS HEREBYrACKNOWLEDGED OF THE SUM OF:
FROM:
Dollars
la
on this day of , 1982 for the purchase of the following
described Cemetery Lot(s) upon the terms and conditions as stated herein:
Description of Property:
Cemetery Lot (s) # /,.2 Block# Unit # _�? a,IVCA,
Purchase Price: 12d Dollars($/ , )
Terms and conditions of sale:
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:
r�
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.
Witness