HomeMy WebLinkAbout2-18-11N
BLOCK 18 (Unit #2)
Terrien, Ovid
Terrien, Mrs. Ovid (Genevieve)
Unit 2, Block 18, Lots 11,
Genevieve interred 1/4/85 - lot 12
Ovid interred 6/16/87 - Lot 11
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Name
Unit
Block
Lot
Date of Mark -out
Date of Burial
6 /'/er
641615r Time /1
Name of Funeral Home
Authorized by
DEED ` 222
Paid by General Receipt No.
222 Dated Oct 22, 1973
TERRIEN, Ovid R & Genevieve
150.00 2 P. 0. Box 656, Sebastian
List Price $ Maximum No. Burial spaces
Total area in square feet Block 18, Unit 2
Discount $ flat Lots 11 and 12
Net Paid C150...00 Monument permitted
(Data above this line for City Record only)
v
A.
(Type or Print)
STATE OF FLORIDA
41PARTMENT OF HEALTH & REHABILITATO SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT
AO/
/ of
Q
1. Name of
Deceased
First
OVID
Middle Last
REYNOLD TERRIEN
DATE Month Day Year
OF
DEATH JUNE 6 1987
2. Place of Death
County
BREVARD
City, Town or Location
TITUSVILLE
Name of (If neither, give street address)
Hosp. or
Inst. JESS PARRISH MEMORIAL HOSPITAL
3. Name of Medical
Certifier JAMES T. NICHOLS, M.D.
4. Funeral Home/ Name
Direct Disposer STRUNK FUNERAL HOMES
Ea Physician
❑ Medical Examiner
Address
1315 GARDEN STREET TITUSVILLE, FLORIDA 32796
Address
1623 NORTH CENTRAL AVENUE SEBASTIAN, FLORIDA 32958
5. Check
Appro-
priate
Box
❑ The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
PAT was contacted on 6/8/87 He /she verified that
this death was from natural causes, that there was no accident nor other external cause of death, and that
DR. JAMES T. NICHOLS, M.D. will complete and sign the medical certification of
b Ef
c
cause of death.
medical certification.
was contacted on He /she verified that
Medical Examiner, will complete and sign the
6. Funeral Director/
Direct Disposer
Signature . j.. Fla. Lic. No. /Reg. No. Date Signed
2088 6/8/87
B.
BURIAL— TRANSIT PERMIT
Permission is hereby granted to dispose of this body.
Registrar or
Sub- Registrar Signatur
Permit No1228 -87 -219
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.
A49-
Date
Issued
JUNE 8, 1987
C.
Signature Medical Examiner Date
AUTHORIZATION for CREMATION, DISSECTION or BURIAL -AT —SEA
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:
vi BURIAL ❑ STORAGE
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person -in- Charge )
CEMETERY OR CREMATORY
Place of Disposition CQ,� ,e?"
Date of Disposition 6 I / 6/e1
- ,� n VI��, 4 .) ['t K)
C.et /Il/
This permit must be endorsed by the Sexton or person -in• arge (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.)