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7 MOUDA DEPARTMENT OF
EALT
0 (TYPE)
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
C;Iq
1. Name of First
Middle
Last
Date
Month Day Year
Deceased
of
Thomas
H.
Lowe
Death
Sept. 16 2002
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
enter
3. Name of Medical
Address
Phone Number
Certifier David DePutron, D. O .
13836 U. S. #1
Medical Examiner fqPh ysician
Sebastian, FL
772 -589 -6888
4. Name of Funeral Home /Bire"ispesel 0
Address
Fla. Lic. No./Reg. No.
Phone No. (Area Code)
1623 N.
Central Ave.
Establishment
Sebastian,
FL
1228
772- 589 -1000
Strunk Funeral Home
5. Check a. U The medical certltication nas Dean compieteo ana signea. A completes cemncate oT seam accompanies tnls
Appropriate application.
Box
b. Jenni was contacted on 9/16102
He /she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. DePutron will complete and sign the medical
certification of cause of death within 72 hours.
C. rj was contacted on He /she verified that
Medical Examiner, will complete and sign the
m ,947al ce.0ification caus f death within 72 hours.
6. Funeral Director/ Z F.E. No. /Reg. No. Date Signed
/ G�2�
-1862 9/16102
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228 -02 -0390
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.
Registiesit or-- ` Date Date Certificate
Subregistrar Signature �.�(,� Issued: 9/16102 Due: 9/21/02
C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA
F91
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.
Method of Disposition:
BURIAL
CREMATION
Signature of Sexton
or Person -in- Charge
STORAGE
DOTHER (Specify)
CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemetery
Date of Disposition 9Ls� O/D °L,-
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.
Distribution. White: Cometery or Crematory
DH 326, 8197 (obsolete- all previous editiorm) Yellow: Funeral Director or Direct Disposer
(Stock Number: 5740000-0326 -2) Pink: Local Registrar
• •
261
THE SEBASTIAN CEMETERY
City of Sebastian
Sebastian, Florida
RECEIPT IS HEREBY ACKNOWLEDGED OF THE SUM OF:
Dollars
FROM: r � /7' a % Ll ti -F /,-,, , 19--, L ®/ _
P f
ov this _day of 1981 for the purchase oftthe following
described Cemetery Lot(jW upon the terms and conditions as stated herein:
Description of Property:
Cemetery Lot (s) # �L�j /,(� Block# Unit# 0
Purchase Price:`
�T /e /rms'and'conditions of sale:
4 1/1 Ili/If 40
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.
Witness
CITY of sEBASTIAN CL
C 10 2 4
CITY CLERK'S OFFICE
RECEIPT _
'o
Na ° Cash
me
Data
. Amourf*ftM i
001001208001
Sales Tax
001501322900
Garage Sales
001501341920
CoWe-Aid Spy
001501341910
LDC/code of Ordinances
001501362100
Community Center Rent
001501362100
Yacht Club Rent
001501362150
Non Taxable Rent
001501343800
Cemetery Lots
601010 343800
Cemetery Lots
LoUNiche --Z--W/—, Block Xlk:p' . Unit
001501369400
Interment Fee
001501369400
Weekend Service
680800 220681
Yacht Club Security Deposit
680800 220682
Community Center Security Deposit
680800 220683
Riverview Park Security Deposit
I Total Paid
i
initlak j
`, wldb – Doot. of Origin • yellow – finorrco • Pink - Applicant i