HomeMy WebLinkAbout2-19-157
SHEET NO
(91e, )
?lock 19
Lots 15, 16 Unit 2
Prillaman, John H. Deed #136
Prillaman, Minnie A.
Riverview Trailer Park %-? b, /3". g 6,
Sebastian, Fla.
Name J t7 // ff., pi( %.� io9 , !% /\✓
Unit CA
Block f 9
Lot
Date of Mark -out
Date of Burial
Name of Funeral Home
Authorized by
/5
Time % O F� �✓/Yl
Paid by General Receipt No. 66 Dated Jan.8, 1970
100.00
List Price
$
Discount $
Na Paid $ *100.00 **
/ -,3 -7d
Maximum No. Burial spaces 2
Total area in square feet
Monument permitted flat
(Data above this line for City Record only)
Deed #136
John H. & Minnie A. Prillaman
P. 0. Box 326
Riverview Trailer Park
Sebastian, Fla.
Lotss 15 & 16, Blk. 19
STATE OF FLORIDA
likARTMENT OF HEALTH & REHABILITA SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
JOHN H. PRILLAMAN DEATH MARCH 20 1986
2. Place of Death City, Town or Location
County
INDIAN RIVER VERO BEACH
Name of
Hosp. or
Inst.
(If neither, give street address)
VERO BEACH CARE CENTER
3. Name of Medical Physician Address
Certifier M. FAROOQ, M.D. ❑ Medical Examiner 777 37th STREET, VERO BEACH, FLORIDA
4. Funeral Home/ Name Address
Direct DisposerSTRUNK FUNERAL HOME 916 -17th STREET VERO BEACH FLORIDA 32960
5. Check
Appro-
priate
Box
a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
b ALICE
c
was contacted on 3/21/86 He /she verified that
this death was from natural causes, that there was no accident nor other external cause of death, and that
DR. FAROOQ will complete and sign the medical certification of
cause of death.
medical certification.
was contacted on. He /she verified that
, Medical Examiner, will complete and sign the
6. Funeral Director/ Signature
Direct Disposer
B.
Fla. Lic. No. /Reg. No. Date Signed
3 -21 -86
URIAL- TRANSIT PERMIT
Permit No.1228 -86 -109
Permission is hereby granted to dispose of this body.
ErA 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
Sub - Registrar Signature
Date
Issued
3 -21 -86
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 cremations.
D. CEMETERY OR CREMATORY
Method of Disposition:
)BURIAL El STORAGE
CREMATION El OTHER (Spe
Signature of 6ex4n_)
or Person -in- Charge )
.
This permit must be endorsed by xton or person -in charge (or by the Funeral Director /Direct Disposer when there is no Sexton)
and returned within 10days to the local County Health Department in the County where disposition occurred.
Place of Disposition., jy S 72-4[x.) .L
Date of Disposition ,�'e'.7'
Deborah C. Krages, City Clerk
HRS Form 326, APR. 81
(replaces previous editions which may be used.)