HomeMy WebLinkAbout2-36-02mu
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Name
Unit
Block
Lot
Date of Mark -out
Date of Burials Time q 'f A �`
Name of Funeral Home
F,
x �•
Authorized by
- Deed #174
Cash.Ck. Seb. Riv.Bk.
Paid by (iaacro�akiWeotpt No. 003467.. • . • • Dated... ,1128/72 ................ James F. & Sadie L. Hubbard
150.00 2 Trout Lane
List Price $ Maximum No. Burial $paces - • • • • • Karr's mobile Home Park
Discount $ ......... Total area in square feet Sebastian, Fla.
p� flat
Net Paid $ 150.00 ...... Monument itted ................ • • • • • Lots 1 & 2, Blk. 36
(Data above this line for City Record only) Unit #2
State of Florida, Oepa of Health and Rehabilitative Services, Vital tistics
A AA FOR BURIAL — TRANSIT PERMIT 3
A. (Type or Print)
`*
1. Name of First Middle
Last
DATE
Month Day Year
Deceased
James Francis
Hubbard
OF
DEATH
March 20, 1993
2. Place of Death City, Town or Location
Name of (If neither, give street address)
County
Hosp. or
Indian River SEbastian
Inst 7330
129th Place
3. Name of Medical Medical Examiner Address Phone Number
Certifier 7754 Bay St.
Farhat Khawaj a, M.D. X Physician (407)589-3000
4. Name of Funeral Home / Address Fla Lic. No. /Reg. No Phone Number (Area Code)
Direct Disposer 6604 20th St.
Indian River Cremations, Inc. Vero Beach, Fl. 32966 000166 (407)234 -5961
5. Check a The medical certification has been completed and signed. A completed certificate of death accompanies
APpro- this application.
priate
Box b ❑ 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 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.
6. Place of Instate cemetery/ C. S. I. Removal
Final Disposition: FXJ crematory - n /county: palm Beach Count from state Donation
7. Funeral Director/ Signature F.E. No. /Reg. No. Date Signed
Direct Disposer KA0000235 March 22, 1993
B. BURIAL — TRANSIT PERMIT 195 -93 -034
Permission is hereby granted to dispose of this body. Permit No.
❑ 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 t ate certificate
Registrar or
Subregistrar Signature
C.
FBI
Signature
Date ate Certificate
Issued: '
AUTHORIZATION for CREMATION, DISSECTION or BURIAL— AT— SEXreme.ton Authwrizatior.
No.
Medical Examiner Date
or
Medical Examiner Frederick Hobin, M.D. gave authorization by telephone to Paul Goodridge
Funeral Director /Direct Disposer. Date 3 -22 -93
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.
Methods of Disposition:
❑ BURIAL
6 CREMATION
Signature of Sexton )
or Person-in-Charge)
❑ STORAGE
❑ OTHER (Specify)
CEMETERY OR CREMATORY
Place of Disposition
Date of Disposition
I 1,9
This permit must be endorsed by the Sexton or person -in- charge (or by the Funeral Oirector /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.
HRS Form 326, Feb 89 (Repieces Oct 87 edition which may be used)
(Stack Number. 5740 -000- 0326 -2)