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STATE OF FLORIDA
W PARTMENT OF HEALTH & REHABILITtOE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT
AA/Z6, 117
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
Raymond Arnold Fischer DEATH Feb. 11, 1983
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Roseland Inst. Sebastian River Medical Center
3. Name of Me d� I ® Physician Address
Certifier Mohammed Farooq, M.D. C] Medical Examiner 777 37th St. Vero Beach Florida
4. Funeral Home/ Name Address
1km1cRjmRwxx Pottinger & Son Funeral Home 1200 S. Indian River Drive Sebastian Florida 32958
5. Check a Ox 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.
6. Funeral Director/
R'3€ kPywA5ekXX
B.
C
ture
was contacted on . He /she verified that
, Medical Examiner, will complete and sign the
# 2368 February 11, 1983
Fla. Lic. No. /Reg. No.
BURIAL— TRANSIT PERMIT
Permit No
Date Signed
759-466
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 D
� `yam ` Z7 r� Sub - Registrar Signature Issue
,
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. Awaiting period of 48 hours after death
is required for all cremations. r
D. CEMETERY OR CREMATORY
Method of Disposition:
IM BURIAL 0 STORAGE
R CREMATION O ER (Specify) x
D -t acv �i,�,
Signature of Sexton _o r
or Person -in- Charge )Deborah C. Krages
City Clerk
Place of Disposition Sebastian Cemetery
Date of Disposition February 14, 1983
This permit must be endorsed by the Sexton or person -in- charge (or by the F ' eral Director /birect Disdbser 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.)
I
Paid by XM &'k fiwceipt No. ....21.8..... .... Dated .... March -24;- -198.1
List Price $.*.*2DO,..ODtA . Maximum No. Burial spaces ......2.....
Discount $......... - 0. -.... Total area in square feet ... - === .......
Net Paid $. **.200.00 Monument permitted ....flat
Rules and Regulations attached (Data above this line for City Record only)
Block 47, Lots 9 and 10, Unit 2 addition
Fischer, Raymond A. and Marie E.
Box 247, Brevard Avenue
Roseland, Florida 32957
DEED #443
Fischer, Raymond A. &
Marie E.
Box 247,Brevard Avenue
Roseland, Florida 32957
Unit 2 addn., Block 47
Lots 9 and 10
DEED #443
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RAYMOND A. FISCHER 3Y�gf 115
MARIE E. FISCHER
P. 0. BOX 247 _.
ROSELAND, FLORIDA 32U7- 63-8419/2670
Pay to the SEBASTIAN b 0_
order of QTY OF { � � � riQ, .
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- Memo: _r�s
1 :26 7064 L991 :20r'- 000006947 2 Real LS
N0. 1) A
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RECEIVED FROM /Z __ e �
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DOLLARS
Account Total $� %_
Amount Paid S
Balance Due $
"THE EFFICIENCYsLINE "AN AMPAO PRODUCT