HomeMy WebLinkAbout2-15-09Name
Unit
Block
Lot
Date of Mark -out
Date of Burial
,; r` Time
Name of Funeral Home). -
Authorized by
Block 15
Lots 9 & 10
Unit 2
James T. and Louise Patteson
P. 0. Box 71
corner Louis St. and Sebastian Ave.
Roseland, Florida 32957
Deed # 332
new address: 186 - 27th Ave., Vero Beach
Paid by General Receipt No. ..121....... .... Dated
List Price
Discount
Net Paid
$ *200.00*
$. • *200:00* ... .
Rules & Regs attached
April 27, 1978
Maximum No. Burial spaces 2
Total area in square feet
Monument permitted Fl a t
Deed # 332
James T. and
;wise Pattisc
P. 0. Box 71
Roseland, Fla. 3295;
(Data above this line for City Record only) BZk 15, lots 9 & 10,
!tcu.a..4,usr; /r6 .i) 721' a,,, VP
FRS
State of Florida, Departm f Health and Rehabilitative Services, Vital illics
APPLICATIt71Q FOR BURIAL — TRANSIT PERMIT
A /C
/5
4/
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased James T. Patteson DEATH 06/01/1992
2. Place of Death
County
Indian River Vero Beach
City, Town or Location
3. Name of Medical
Certifier
Gerald Pierone. Jr.. M.D.
4. Name of Funeral Home/
Direct Disposer
Strunk Funeral HomPS,
5. Check a ❑
Appro-
priate
Box b
Name of (If neither, give street address)
Hosp. or
Inst.
Indian River Memorial Hosoial
Medical Examiner
Physician
Address
Address Phone Number
3850 20th Street
Vero Beach, Florida 32960 (407)562 -8447
Fla. Lic. No. /Reg. No. Phone Number (Area Code)
916 17th Street
P.A. Vero Beach, F1 32960
The medical certification has been completed and
this application.
130 (407)562 -2325
signed. A completed certificate of death accompanies
Dianc was contacted on 06 /02 /1992.within 72
hours after death. He /she verified that this death was from natural causes, that there was no accident
nor other external cause of death, and that .f rs+Jd PieronQ, Jr , M D will complete
and sign the medical certification of cause of death.
c ❑ was contacted on He /she verified that
, Medical Examiner, will complete and sign the
medical certification.
6. Place of Sebastian Cemetery In state cemetery/ Removal
Final Disposition: n crematory - name /county: Indian River n from state n Donation
zSignaJu , F.E. No. /Reg. No. Date Signed
7. Funeral Director/
2089 06/02/1992
B. BURIAL — TRANSIT PERMIT
Permission is hereby granted to dispose of this body.
❑ A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted as undue hardship
would result from filing within the normal time limit. If the certificate cannot be filed within this extended time limit, a "Funeral Director /Direct
Disposer Report" will be filed with the Local Registrar of the County in which death occurred.
❑ No extension of time for filing the death certificate requested.
Sub t Signature M Date 'Issued: (t' q Z Due � ar GeV,* Z..
Permit No 0130 -92 -0281
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. CEMETERY OR CREMATORY
Methods of Disposition:
® BURIAL
❑ CREMATION
Signature of Sexton )
or Person -in- Charge )
❑ STORAGE
❑ OTHER (Specify)
Place of Disposition Sebastian Cemetery
Date of Disposition June 4,1992
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)