HomeMy WebLinkAbout2-41-03a
r-
Name I G
Unit
Block
Lot
Date of Mark -out—
Date of Burial
Time
Name of Funeral Home 4,r
s.
Authorized by
Block 41 _ _ _ --
Lots 3, 4 Unit 2
Harmon, Mrs. Edward (Viola) Deed #245e�
Harmon, Edward (Interred)-
P•0. Box 252 (Palmetto Avenue)
Sebastian, Fla. 32958
�n
1
Paid by
b-'— ' Receipt No.
. ....... .... Dated....... �� "; �!,.r•C.
.....
Iast Price $. , �,SZ?, :.. . c-L
Discount $
Maximum No, Burial spaces �, • . , ,
"
Total area in
Net Paid $ ..�S"L� square feet .... CO. T......
z���� s` Monument permitted .. .
J
(Data above this line for
IF Record only)
•,�� -Z
STATE OF FLORIDA
OARTMENT OF HEALTH & REHABILITA0 SERVICES 16 /
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT
A.
(Type or Print)
1.
Name of
First
Middle
Last DATE Month Day Year
Deceased
Vola
Harmon DEATH Jan, 28, 1986
2.
Place of Q_eath
City, Town or Location
Name of (If neither, give street address)
County revard
Hosp. or
t>itdtXX cRiXffc
Melbourne
Inst. Florida Conv. Home
3.
Name of Medica1 McPhysician
Address
Certifier John Potomski,
Do. ❑ Medical Examiner
720 E.. New Haven Melbourne Fla.
4.
Funeral Home/
Name
Address
�Pottinger
& Son Funeral Home 1200 S. Indian River Dr, Sebastian F1otida
5.
Check a
The medical certification has been completed and signed. A completed certificate of death accompanies
Appro-
this application.
priate b
Box
❑
was contacted on . He /She verified that
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.
c
❑
was contacted on . He /she verified that
Medical Examiner, will complete and sign the
'
medical certification.
_lope
2358 Jan. 28,, 1986
6.
Fun ral Director/
Signature
Fla. Lic. No. /Reg. No. Oate
Signed
B.
C
BURIAL — TRANSIT PERMIT
Permit No. X759 -641
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 y� Date
Sub- Registrar Signature����,;�•LLLI lt� Issued
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. Awaiting period of 48 Flours after death
is required for all cremations.
D. CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition Sebastian Cemetory
January
Ea BURIAL ❑ STORAGE Date of Disposition
,j, 198G6
❑ CREMATION ❑ OTHER (Specify)
Signature of Se narge
1 -C
or Person -in -C
_Z—,--Deborah C. Kraiaes. ?CjtVClerl
This permit mus a endorsed by the Sexton or person- in- cfiiarge (or btiGtfie 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.
HRS Form 326, APR. 81
(replaces previous editions which may be used.)
ICE M
dex:RECORD #
City of Sebastian, FL - Cemetery Lots
Name HARMON First Name UILOA
ss 1 Palmetto Ave. P.O. Box 252
ss 2
City
Deed #
Unit #
Lot Number
Lot Number
Lot Number
Lot Number
Comment
Comment
<
Sebastian State F1
245 Date 06 -12 -74 Amount
2- Block # 41
3 Interred HARMON, UILOA
4 Interred HARMON, EDWARD
Interred
Interred
these 2 have no markers
>dit <D
>rev
Zip
$150
Record:
32958-
Dte Interred 01 -30 -86
Dte Interred - -74
Dte Interred
Dte Interred
<L >abel <T
Friday, Mar 04, 2005 11:31 AM
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