HomeMy WebLinkAbout2-20-0197
Paid by No. /' PJ 5 Dated 0 /1,?./
List Price $ 04' /3—d. — Maximum No. Burial spaces
Discount $
Net Paid $
Total area in square feet. ..G?.1........
Monument permitted
(Data above this line for City Record only)
A. • ^' e 6 / L
BALANCE
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Paid by Gefteleeip e.,-.-2-- ... ... Dated A qo /12
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List Price $ .,?5:.#ce 0" /3-6.. — ,.
Maximum No. Burial spaces
Total area in square feet (''' 7/
Monument permitted
(Data above above this line for City Record only)
Discount $
Net Paid $
......
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APPLEQUIST., Allen 3/)-‘1 g.C.
APPLEQUIST, George (Interred) 7243c /73
,SA 5 e-4 (C
54- ice;
UNIT 2, Block 20, Lots I, 2
DEPARTMENT OF HEALTH AND REHARILIIATIVE SERVICES
• VITAL STATISTICS
APPLICATION FOR BURIAL -TRAIT PERMIT
NAME OF First Middle Last DATE Month Day Year
O
DECEASED Ellen Applequist fDEATH March 24, 1980
(Type or print)
PLACE OF DEATH
COUNTY
Brevard
CITY, TOWN, OR LOCATION
Melbourne
NAME OF (If not in hospital, give street address)
HOSPITAL 0
INSTITUTIOr'lorida Cony. Home
Attending Physician g] (Name of Medical Certifier) (Address)
Medical Examiners G Louis Nelson, D.O. 720 E. New Haven Avenue Melbourne Florida 32901
Funeral (Name) (Address)
Home Colonial Funeral Home S. Indian River Drive Sebastian Florida 32958
Check A ® A completed certificate of death accompanies this application.
One
B [ ] Dr. was contacted on ,19
He has assured me that this death was from natural causes and that he will complete and sign the medical
certification of cause of death.
C [i The attending physician was unavailable or this death comes within the Medical Examiners jurisdiction.
The body was released to me by
on ,19
(Signature)
Funeral
Director
(Fla. Lic. No.) (Date Signed)
BURIAL TRANSIT PERMIT
Permit
No.
759 -262
Permission is hereby granted to dispose of this body by burial, transportation out of state, storage or cremation. For cremation a
waiting period of 48 hours after death must be observed and the Medical Examiner's approval must also be obtained.
j A five day extension of time for filing the death certificate has been requested and granted.
Signature of
Registrar
Date
Issued
Method of Disposition
!k BURIAL
p CREMATION
pi STORAGE
] OTHER(Specify)
Signature of Sexton
. Person in Charge
CEMETERY OR CREMATORY
Date of .
Disposition
Place of
Disposition
March 27, 1980
Sebastian Cemetery
This permit must be endorsed by the sexton or person in charge (or by the funeral director when there is no sexton) and returned
within 10 days to the local county health department.
HRS Form 326 (1/77)