HomeMy WebLinkAbout2-48-15I-
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Name
10
Unit
Block
Lot
Paid by General Receipt No. 19 8 DEED
••••• •�.. Dated..A�?�ust 4, 1980
List Price
Maximum No.
Discount $, , . Burial spaces
Net Paid g,* * 350 , 0 0 * *
Total area in square feet ..... .
Monument petmltted f1 a t
,. R &R -__-_ Attached
_ ___ (Data above this line for City Record oaly)
WELLS, Phyllis
(Daughter- in,law of
Prank Ward, deceased
Box 301- B,Nicco Rd,S4
lan, Pl.
BLK 48
,Lots 15, & 16
WELLS, Phyllis
Box 301 -B
MiCCO Road
Sebastian, Fl
X filed: Frank Ward
DEED #405
Blk 48 Lots 15 & 16 alZllT
Phyllis' father in law, Frank Ward,
on 8 -7 -80. interred in Lot 15
Maudie Ward - Cremains interred 5/23/88 - Lot 15
LOT 16 UNUSED
BLOCK 48 LOTS 15 & UNIT #2 ADD'N
DEED #405
Mrs. Phyllis Wells
Box 301 -B
MiCCO Road
Sebastian, F1 32958
Frank Ward (father in law) interred in
Lot 15 on 8 -7 -80.
Maudie Ward - Cremains interred 5/23/$$ _
Lot 15
LOT 16 UNUSED
t
F DEATH
OCCURRED N
NSTITUTIOK
SEE HANDBOOK
REGARDING
COMFLETION OF
RESIDENCE ITEMS
omm
DISP
CONDITIONS
F ANY
WHICH GAVE
,:;-- RISE TO
IMMEDIATE AUTHORITY FOR BURIAL, TRANSPORTATION, REMOVAL
CAUSE
STATRwTHE rDIRE THIS BURIAL -TRANSIT PERMIT, WHEN COMPLETELY FILLED IN AND BEARING ABOVE THE SIGNATURES OF THE ATTENDING PHYSICIAN AND FUNERAL
UNDERLYING CT OR, CONSTITUTES AUTHORITY FOR BURIAL, TRANSPORTATION AND REMOVAL OF THE DECEASED NAMED ABOVE. (THIS IS NOT AUTHORITY FOR
CAUSE LAN7
CREMATION, A SEPARATE APPLICATION MUST BE MADE.)
CEMETERY OR CREMATORY AUTHORITY SHALL FILL OUT SECTION BELOW
THE DECEASED NAMED ABOVE WAS BURIED E CREMATED [-] IN THE CEMETERY OR CREMATORY NAMED IN REM 19b.
BURIAL WAS IN SECTION LOT GRAVE HAVE MADE THE APPR IATE ENTRY IN THE CEMETERY OR CREMATORY
REGISTER.
SEXTON OR OTHER
SIGNATURE PERSON IN CHARGE
THIS BURIAL - TRANSIT PERMIT MUST BE SIGNED ABOVE B TH CEMETERY OR CRfMATORY AUTHORITY. WHERE THERE O ll-TIME PERSON IN CHARGE
OF THE CEMETERY, THE FUNERAL DIRECTOR MAY SIGN AS SEXTON.
FORM- VS -002 THIS PERMIT MUST BE RETURNED WITHIN TEN DAYS TO THE WEST VIRGINIA STATE DEPARTMENT OF HEALTH
REV. I -7e
DIVISION OF VITAL STATISTICS
LOCAL FIE NUMBER PHYSICIAN'S MTMCATE OF DEATH CTAW on •n n _
DECEDENT —NAME FIRST MIDDLE LAST
P. L.�� :�
SEX^'" DATE OF DEATH(M.., Dry, Yrj
2.f L x)11 �. _S_
RACE- (..q., WWM, Black, Am. IAGE
T�Indian .k. apocf
4. B HTYi,
—Last Birthday
./ -
Sa.
UNDER 1 YEAR
UNDER 1 DAY
DATE OF BIRTH (Mo., Dry, Yr.)
�L
6. V
COUNTY OF DEATH
^ //r`/
70. ` f ,V"l'wll
MOS.
5b.
DAYS
,
HOURS ; MNS.
5c.
CRY, TTOWN OR LOCATION OF DEATH
7b. �N '. I C. {ti
HOSPITAL OR OTHERtNSTITUTION —Nam• (N not in •itk«, Biro dwN.and nwnb.r)
7c. W N' /C n jy�1 . '�%�C 7
F HOSP. OR INST. kldkal• DOA,
Oa/Em«. RrI� Y of A 1
'�"
STATE OF BIRTH (N not in U.S.A,
nom• cowNry)
e. KY.
CITIZEN OF WHAT COUNTRY
19. U. 8. E
MARRED, NEVER MARRED,
WIDOWED, DIVORCED (Specify)
lo. WIDOWED
NNG S IN wif., maw_ nan.)
Ill.
WAS EVER N U.S.
ARMED FORCES?
(1NpeeNyY•s «N.) NO
SOCIAL SECURITY NUMBER
ZlAd — J / „ ,/
13.7 (� 7
USUAL OCCUPATION (Gim kind of work dam during owd of
working life,. ;f re lnwd)
14..HOUSEWIFE
KIND OF BUSINESS OR INDUSTRY
1
RESIDENCE —STATE
�R
)Saar. VA.
COUNTY
1
CITY, TOWN OR LOCATION
iu.BQUEFIELD
STREET AND NUMBER
lisdI715 BLFD. AVE.
Imm CRVI.WIRS
r. «N.)
";w YES
FATHER —NAME FIRST MIDDLE LAST
MOTHER —MAIDEN NAME FIRST MIDDLE - LAST
16. ALBERT POWERS
117. LOTTIE COX
INFORMANT —NAME (Type or print)
MAIM ADDRESS STREET OR R.F.D. NO. CRY OR TOWN STATE ZF
1eYHYLLIS WELLS
,86.803 S.SEA GUILL BAREFOOT BAY, FLORIDA 32958
BURIAL, CREMATION, REMOVAL, OTHER (Sp.cify)
CEMETERY OR CREMATORY —NAME
LOCATION CRY OR TOWN STATE
19aCREMATION i REMOVAL
191i.SEBASTIAN CEMETERY
,,SEBASTIAN, FAGRIDA
FUNE&UqfRVICE LICENSEE Or P.rson tq
20a.
NAME OF FACILITY
2obCRAVENS-- SHIRES F. HOME
ADDRESS OF FACILITY
2,DLUEWELL, W.VA. 24701
To tha bast of my k.o - " , daaM occ r*d at 114 tim•, daN and place and dw ro tM -
3 caw•(,) stand.
DATE SIGNED (Ms., Dry. Yr.)
HOUR Of DEATH
21a. (Signature)
M
l _ nrus�c yr wnncnunv rnsant.uw r�nrrcn
V 21d.
s ! NAME AND ADDRESS OF CERTF R (Type or
21..
�m weK (type or►nnq
DATE RECEIVED BY REGISTRAR (Me., Dry. Yr.)
22b.
BURIAL /TRANSIT PERMIT