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BLOCK 18
(Unit #2)
Paid by General Receipt No. 219 ........ Dated..0c t..22,..1973 ..........
List Price 1$. 2C10..01 ..... . Maximum No. Burial spaces .. 2 ......
Discount $ .... - .............. Total area in square feet ................
Net Paid $. 2.00.00 Monument permitted ..... ..........
(Data above this line for City Record only)
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FREDERICK, Armand & Dahlia
P. 0. Box 1B6
Sebastian
DEED #220
Block le , Lots 5 & 5
Unit #2
(Maple Street, Wi0Jood)
0-611-4.xl
/6P‘:
A.
(Type or Print)
STATE OF FLORIDA j�
OPARTMENT OF HEALTH & REHABILITAlly SERVICES .� �` I C� �! c9
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT
1. Name of
Deceased
First
Delia
Middle
Eva
Last
Frederick
DATE Month Day Year
OF
DEATH Oct. 20, 1982
2. Place of Death
County
Indian River
City, Town or Location
Vero Beach
Name of (If neither, give street address)
Hosp. or
Inst. Indian River Memorial Hospital
3. Name of Widical
Certifier tuward Attarian,
4. Funeral Home/
5. Check
Appro-
priate
Box
M.D
AZ Physician
Name
Address
❑ Medical Examiner 1300 36th Street Vero Beach, Fla. 32960
Address
Pottinger & Son Funeral Home S. Indian River Dr. sebastian Florida 32958
a El The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
b ❑
c ❑
was contacted on 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.
6. Funeral Director/
xliNikcPSCKPgircx
n)erdic,i31 cer ,Xificatio
%
Signa f�
was contacted on He /she verified that
Medical Examiner, will complete and sign the
2368 October20, 1982'
Fla. Lic. No. /Reg. No. Date Signed
B.
/ BURIAL — TRANSIT PERMIT
Permission is hereby granted to dispose of this body.
a
Registrar or
Sub - Registrar Signature
Permit No 759 -443
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.
1 1 - :7;/.
Date
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 cremations.
D.
Method of Disposition:
ig BURIAL
❑ CREMATION
❑ STORAGE
❑ OTHER (Specify)
Signature of Sexton )
or Person -in- Charge )
CEMETERY OR CREMATORY
/
/
Place of Disposition Sebastian Cemetery
Date of Disposition October 23, 1982
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 County Health Department in the County where disposition occurred.
HRS Form 326, APR. 81
(replaces previous editions which may be used.)