HomeMy WebLinkAbout2-47-12F
w
x
W
u
z
mI
x
0 V
Q
u!
h �;U
t
J
Ei 0
ii4!
en
.�
a1?
Paid by f9 Heeeipt No. ...241........... Dated .....
�-z.Q- 81... ...:.........
List Price $•• *.200,•OQ*
Maximum No. Burial spaces ... 2 .
Discount $ • —0— • • • • , • • • • -
• • • Total area in square feet —°' ° --
Net Paid $. , • *•$200.00 .4a • • . • • • . � - -�
Monument Permitted ,f.1 a t• • • ......... .
Rules & Regulations Sent (Data above this line for City Record only)
i
i
'^ t
q �
DEED #445
Pederquist, Arthur
Gertrude
865 Lance Street
Sebastian, Florida
Unit #2 Addn., Bloch
Lots #11 &12.
a Hk"1►Ltit l iVE S F1f7iCE5
VITAL STATISTICS
*PLICATION FOR BURIAL-TRAS PERMIT
NAME OF First
Middle
Last
DATE Month Day Year
D ypeAoSPD t) Gertrude
STORAGE
Pederqui st
IDEATHMay OF
20, 1981
PLACE OF DEATH
COUNTY
I CITY, TOWN, OR LOCATION
NAME OF
HOSPITAL
(If not in hospital, give street address)
OR
Indian River
Sebastian
INSTITUTION 865 Lance Street
Attending Physician XJ
(Name of Medical Certifier)
(Address)
Medica! Examiners ❑ Muhammad
Farooq, M.
D., Washington Plaza,
Sebastian, Fla. 32958
Funeral (Name)
Cox - Gifford - Romani
P. A., P. 0.
(Ad ress)
Box 1113, 1950 20th St., Vero each, Fla.
Home
Check A ❑ A completed certificate of death accompanies this application.
One
B ® Dr. Muhammad Faroog was contacted on May 20 19 81
He has assured me that this death was from natural causes and that he will complete and sign the medical
certification of cause of death.
C ❑ The attending physician was unavailable or this death comes within the Medical Examiners jurisdiction.
The body was released to me by
on
,19
(Signature) (Fla. Lic. No.) (Date Signed)
Funeral r
Director #868 May 20, 1981
BURIAL TRANSIT PERMIT Pe
No
mib- 129 -1981
Permission is hereby granted to dispose of this body by burial, transportation out of state, storage or cremation. For cremation a
waiting period of 48 hours after death must be observed and the Medical Examiner's approval must also be obtained.
® A five day extension of time for filing the death certificate has been requested and granted.
Signature of
Registrar
Method of Disposition
®
BURIAL
❑
CREMATION
❑
STORAGE
❑
OTHER(Specify)
Signature of Sexton
Date May 20 1981
Issued
CEMETERY OR CREMATORY
Date of May 22, 1981
Disposition
Place of Sebastian Cemetery
Disposition Sebastian, Indian River Co., Fla.
or Person in Charge"
_.sf
This permit must' be endorsed by 04 sexton or person in charge (or by the funeral director when there is no sexton) and returned
within 10 days to the local county health department.
HRS Form 326 (1/77)