HomeMy WebLinkAbout2-16-11Nov. 30, 1977
Paid by General Receipt No. ..99........ .... Dated ..............................
List Price $...*�DD.00*,,.,
Discount � ..................
Net Paid �...*.20.0..00..*....
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!vlaximum No. Burial spaces ...?........
Total area in aqnare feet ................
Monument permitted. . . . . . . . F18t, . , . , . , ,
(Data above Yhis line for (:ity Record only)
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Mr. F.J. & Mary L. Jone
318 �chumann Dr., Se�. 'I
��Y�c.,EU': rp: i 35' �� �e-i�lc.;4%jl6:�t,
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Deed # 323
Blk 16, Lots 11 & 12, U
Block 16
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Lot 11 and 12 Unit 2
F J and Mary L. Jones ,
- 318 5chumann Drive (formerly)
Deed # 323 mailed to 138 Mockingbird Lane
Delray Beach, 33445
Mary L. interred Z2/2/77
Franklin J. interred 7/30/83
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STA(EOr rWR1UA
EPARTMENt OF HEALTH & REHABiL1�VE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERNIIT
,� // � j� 1��,_
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased O F
Franklin James Jones DEATH July 28, 1983
2. Ptace of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Vero Beach Inst. Vero Beach Care Center
3. Name of Medical �Physician Address
Certifier Freddie Delacruz, M.D. ❑ Medical Examiner 3615 20th St. Vero Beach, Florida 32960
4. Funeral Home/ Name Address
Pottinger & Son Funeral Home 1200 S. Indian River Drive Sebastian Flor.i..da 3295r
5. Check a� The medicat certification has been completed and signed. A completed certificate of death accompanies
Appro-
priate
Box
6. Funeral Director/
��3m[
this application.
b� was contacted on . He/she verified that
this death was from natural causes, that there was no accident nor other externaf cause of death, and that
II complete and sign the medical certification of
cause of death.
c� was contacted on . He/she verified that
�
Signature
Medical Examiner, will complete and sign the
� � ��2368
Fla. Lic. No./Reg. No.
BURIAL—TRANSIT PERMIT
July 28, 1983
Date Signed
Permit No. �59-498
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. 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.
Registrar or �� ���� � Date �� Q � �
Sub-Registrar Signature t'�' Issued ;' � O � �
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA
Signature
or
, Medical Examiner Date
Medical Examiner, , gave authorization by tetephone 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
Method of Disposition: Place of Disposition Sebastian CemeteL'y
�] BURIAL � STORAGE Date of Disposition July 30, 1983
� CREMATtON � OTHER (Specify) � - �
Signature of Sexton ►
or Person-in-Charge )
This permit must be endorsed by the Sexton or
and returned within 10 days to the local County
HRS Form 326, APR. 81
(replaces previous editions which may be used.)
�.
�-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton)
Oepartment in the County where disposition occurred.