HomeMy WebLinkAbout2-18-12DEED # 222
Paid by General Receipt No. 222 Dated Oct 22, 1973 TERRIEN, Ovid R & Genevieve
List Price 150.00 Maximum No. Burial spaces 2 P. O. Box 656, Sebastian
Discount $ — Total area in square feet Block 18, Unit 2
Net Paid $ •150•:00 Monument permitted flat Lots 11 and 12
(Data above this line for City Record only)
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BLOCK 18 (Unit #2)
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BLOCK 18 (Unit #2)
STATE OF FLORIDA p
INPARTMENT OF HEALTH & REHABILIT•OE SERVICES 4 /a £l r� Q02
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
OF
Genevieve Lucy Terrien DEATH January 1. 1985
Deceased
2. Place of Death City, Town or Location , Name of (If neither, give street address,
County Hosp. or
Indian River. Sebastian Inst. H }1oapital- SebOtian
3. Name of Medical ZI Physician Address
Certifier Na8ir Riztoi, M.D. ❑Medical Examiner 7754 Bay St. Site 7, Sebastian, Florida
4. Funeral Home/ Name Address
Pkm*Ammr Strunk Funeral Home 734 N. Central Avenue, Sebastian, Florida
5. Check a 0 The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate -
Box
c
Pmt was contacted on , 1 /2JRR . KeIahe verified that
this death was from natural causes, that there was no accident nor other external cause of death, and that
.pr. NaBir Rizwi will complete and sign the medical certification of
cause of death.
medical c: ification.
Signature
6. Funeral Director/
/1.101413111ENAKrX
B.
Of , t I 'tile
was contacted on He /she verified that
Medical Examiner, will complete and sign the
P.
Fla. Lic. No. /Reg. No. Date Signed
BURIAL — TRANSIT PERMIT
Permission is hereby granted to dispose of this body.
Registrar or
Sub- Registrar Signatu
Permit No.122Q -85 -2
A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and
grant If it cannot be filed within this time limit, a "Funeral Director /Direct Disposer Report" will be filed
wit/ e Local Registrar of t4j County in which death occurred.
Date
Issued i4nyCJ'! 2. 1985
C.
or
AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
Medical Examiner pate ,
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
k ethod of Disposition:
BURIAL D STORAGE
0 CREMATION 0 OTHER ( ify)
Signature of-Sex-tow-1-
or Perin -in- Charge )
Place of Dispositio
Date of Disposition
Deborah C. Krages, Sebastian City Clerk
This permit must be endorsed •y ' todor 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.)