HomeMy WebLinkAbout2-19-16SHEE7' NO
Paid by General Receipt No.
100.00
List Price
Discount
Net Paid
$
$ *100.00 **
66 Jan.8, 1970
Dated
Maximum No. Burial spaces 2
Total area in square feet
Monument permitted flat
44,414.41_, (Data above this line for City Record only)
Name
Unit
Deed #136 ,..
John H. & Minnie A. Prillam
P. 0. Box 326
Riverview Trailer Park
Sebastian, Fla.
Lots 15 & 16, Blk. 19
Block 9
Lot
Date of Mark -out 1 Jo, I 5 cal
it
Date of Burial
/.7) /99;-.
Name of Funeral Home 51-1 t/v'
Authorized by
Time
1
A.
State of Florida, Department of Health and Rehabilitative Services, Vital S istics
APPLICAT.FOR BURIAL — TRANSIT PERMIT
(Type or Print)
1. Name of
Deceased
First
Minnie
Middle
A.
Last
Prillaman
DATE Month Day Year
OF
DEATH 08/07/92
2.
3.
4.
5.
Place of Death City, Town or Location
County
Tndiun River
Name of Medical
Certifier
George MitchPl1, n -0_
Name of Funeral Home/
Direct Disposer
Strunk Funeral
Check
Appro-
priate
Box
SPhaat-iam
Name of (If neither, give street address)
Hosp. or
Inst.
Medical Examiner
—1 Physician
Address
1026 Inrian River Dr #20
Address Phone Number
O.S. #1
13855
13855 i am, Ploridn 32958
Fla. Lic. No. /Reg. No
1623 North Central Avenue
Hnnes, P -A Sabastian, F1 32958
a ❑ The medical certification has been completed and
this application.
b
c ❑
signed. A
hours after death. He /she verified that this death was from
nor other external cause of death, and that Ccorgc Mitchell, D.O.
and sign the medical certification of cause of death.
Phone (Area Code)
1228 (407 562 -2325
completed certificate of death accompanies
was contacted on 08/08/92 within 72
natural causes, that there was no accident
will complete
medical certification.
was contacted on He /she verified that
Medical Examiner, will complete and sign the
6. Place of q h tian Cemetery
Final Dispo i I
7. Funeral Director/
Direct Disposer
In state cemetery/
atory - a , ounty:
Removal
TnH i an River 7 from state n Donation
F.E. No. /Reg. No. Date Signed
B. BURIAL — TRANSIT PERMIT
Permission is hereby granted
❑ A five day extension of time
would result from filing within
Disposer Report" will be filed
❑ No extension of time for filin
Registrar or
Subregistrar Signature
to dispose of this body.
Permit No 1228 -92 -0373
for filing the death certificate (exclusive of weekends) has been requested and granted as undue hardship
the normal time limit. If the certificate cannot be filed within this extended time limit, a "Funeral Director /Direct
with the Local Registrar of the County in which death occurred.
e death certificate requester,,
Date
Issued*
7 7 9,3 Due Date Certificate
�J
C.
AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
Signature
or
Medical Examiner,
Medical Examiner Date
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.
Methods of Disposition:
®(BURIAL ❑ STORAGE
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person -in- Charge )
CEMETERY OR CREMATORY
/
Place of Disposition S e b a s t i an C e m e t e r v
Date of Disposition August 12, 19 9 2
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.
HRS Form 326. Feb 89 (Replaces Oct 87 edition which may be used)
(Stock Number: 5740- 000 - 0326 -2)