HomeMy WebLinkAbout2-30-02s --� -�-
z
LWA
/
�
K
f•
��v
I
Name
Unit
Authorized by
Mack 30
Lots 1, 2
Johns, Mrs. John Be (Ka,thleene) Deed #232
Johns, John B.
P.O. Box 43
Fellesmere, Fla.. 32948
JOHN B. JOHNS interred 10/28/85 - Lot 2
244 Feb 22, 1974
� 245 IYler 1, 1974
Paid by% (reneral ]t3eceiptSNo. Dated ..............................
List Price $.. 200! P9....... Maximum No. Burial spaces ..... .... .
Discount $...... - .......... Total area in square feet ................
Net Paid $ ... 200900 ...... Monument permitted ....Flat ...........
(Data above this line for Qty Record only)
Unit 2
DEED #232 V
John B. & Kathleene Johns
P.O.Box 43
Fellsmere F1 32948
Blk 30, Lots 1 & 2 - Unit #2
�a
STATE OF FLORIDA 16 ad, a6z
ORTMENT OF HEALTH & REHABILITATISERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT
A.
(Type or Print)
1.
Name of First Middle
Last
DATE Month Day Year
Deceased
OF
JOHN B.
JOHNS
DEATH f) T 25 1985
2.
Place of Death City, Town or Location
Name of
(If neither, give street address)
County
Hosp. or
BRE ARD MELBOURNE
Inst. HOLMES
REGIONAL MEDTCAL CENTER
3.
Name of Medical 9PFhysician
Address
Certifier CHRI51jNE McCARTY. M.D. ❑Medical Examiner
4.
Funeral Home/ Name
Address
Direct Disposer STRUNK FUNFRAI HnMF 71A N _ rFNTRAI
AVrNlIF
rFRecTTAN ri nRTna 12QRA
Check
Appro-
priate
Box
f
C.
The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
Dr. McCart.y's Secretary was contacted on 10/281 UWshe verified that
this death was from natural caws, that t4aw was rwji"ident nor other external cause of death, and that
Doctgr McCarty will complete and sign the medical certification of
cause of death.
was contacted on . He /she verified that
Medical Examiner, will complete and sign the
medical certification.
6. Funeral Directors / Signature Fla. Lic. No,49a@r#4e.— Date Signed
Simese
e. BURIAL— TRANSIT PERMIT X228..85 -350
Permit No.
Permission is herg0yegranted 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 Date 10 -26 -85
Sub- Registrar Signature Issued
C. 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 cr #"tions.
D. CEMETERY OR CREMATORY
ethod of Dispasi,�lon: Place of Dispositio
sr
BURIAL Q STORAGE Date of Disposition /a' 07,p
C] CREMATION 0 OTHER (Spec
Signature of £eem n )
or Person -in- Charge )
Deborah C. K
This permit must be endorsed by the Sexton or perion- ir;QFiafgd (or by the Funeral Director /Direct Disposer when there is no Sexton)
and rfturned 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.)