HomeMy WebLinkAbout2-42-12-/l -1-71 -/9
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Name Al 'ek /2 If- cur
Unit
Block !
Lot 12—
Date of Mark -out
Date of Burial /21,7 5 . Time
Name of Funer 1 Home A KA
Autbh�otized by
CEMETERY DEED #477
Paid by ,*AWj0XReceipt No. ..2.87 ......... . , , Dated.. 11 -10 -81
ARTHUR H. YOUNG AND OR
List Price >6..QQ. !?Q....... Maximum No. Burial spaces ....2....... KATHERINE YOUNG
* * * * * 740.0 _. JecansDri ve, _ Lot ..7-_ .
Discount
200.00 Sebastian, Florida 32958
Net Paid E..... ....... Monument permitted .fJa� ..............
R. & R. ISSUED WITH DEED
(Data above this line for City Record only) LOTS 11 &12, B1k.42A,Unit 2addn.
YOUNG, ARTHUR H. AND /OR
YOUNG, KATHERINE
7400 JEANS DRIVE, LOT #7
SEBASTIAN, FLORIDA 32958
LOTS 11 & 12 BLOCK 42A
M
DEED # 4.77
'i
I
UNIT #2 addn.
State of Florida, Departmen eaath and Rehabilitative Services, Vital St cs
APPLICATIOI�INOR BURIAL — TRANSIT PERMIT of
ya
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased Katherine Young DEATH 12/04/95
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Brevard Melbourne Inst. West Melbourne Health Care Center
3. Name of Medical Medical Examiner Address Phone Number
Certifier 720E. New Haven Avenue
John Potomski, M.D. X Physician Melbourne Florida 32901 (407)724-4545
4. Name of Funeral Home/ Address Fla. Lic. No. /Reg. No. Phone Number (Area Code)
Direct Disposer 1623 North Central Avenue
Strunk Funeral Homes P.A. Sebastian F1 32958 1228 (407)562-232
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b ZI Delores was contacted on within 72
hours after death. He /she verified that this death was from natural causes, that there was no accident
nor other external cause of death, and that John Potomski , M.D. will complete
and sign the medical certification of cause of death.
MW
medical certification.
was contacted on . He /she verified that
, Medical Examiner, will complete and sign the
6. Place of Sebast i an Cemetery In ate cemeter Removal
Final Disposition: ematory - e ounty: Indian River from state Donation
7, Signatur F.E. No. /Reg. No. Date Signed
Direct Disposer / 946 L 19 /r)A 10r,
1 B.
1 C.
Im
BURIAL — TRANSIT PERMIT
Permit No. 1228 -95 -0525
Permission is hereb
y 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 as undue hardship
would result from filing within the normal time limit. If the certificate cannot be filed within this extended time limit, a "Funeral Director /Direct
Disposer Report" will be filed with the Local Registrar of the County in which death occurred.
❑ No extension of time for filing the death certificate requested.
qP �� � C� Date � Date Certificate
Subregistrar Signature Issued: � Due:
AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
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.
CEMETERY OR CREMATORY
Methods of Disposition: Place of Disposition 1.= I
BURIAL ❑ STORAGE Date of Disposition 9s"
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person -in- Charge)
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 HRS County Public Health Unit in the County where disposition occurred.
IHRS Form 326. Feb 89 (Replaces Oct 87 edition which may be used)
(Stock Number: 5740- 000 - 0326 -2)