HomeMy WebLinkAbout2-16-15_ t.�
' _.
_.S.' > �
: �
��� � , : � ,� s, � °� � ,/
�1 o���a � _ � ,r �
i � ��`"
�� � rJ �li�� � c 1''� �
��y� �'
J �� �P�" V 7�"" � � � � �
G+� ��\� -� � � n �
�� .�� , .�ry'¢a� $� ,\��` � �1`�
\��, � �I -a7-�° � `��:'
� ql� b'
9 ���.� i� �' /� V; �� � � � � �,
o� ;, �,�' �`� , .��
,c _ � �
� �� � �,�' ;
� � .��
;
�))) � , C �,,
. � :�� � � �sh��� � '{
� � '.
:. - . ., . . . . � ' . . . . ....4.,. ' . . .. : '�. : ",
� . . � .. � . � .. �� �,: � _
+ I ( �
__ . }; i � � � i ; � m
�.._ : i � i i
.--- I
r ;
_ _ _� li I� _ � ` ; � ; ,1 �r_ � _� � � �
I
BLOCK 16 LOT IS UNIT 2
Mrs. AcquZia BenCe
R�ute 1, Box 600 A
W`st Main Street
Citz�
�c$�l,�t� �e�c � > n �e,rre�
�
DEED #296
,
��%a,.5��1
—�
DEED #296
Paid by General Receipt No. . . . . .6.�`. . . . . . . . . . Dated.A�g .23,. ,.j 97E . . . . . , , . . , . BLOCK 16 LOT 15
UNIT 2.
Iast I'rice $ 100. 00 , , . , . , . , Maximum I�'o. Burial spaces . . . . .1. . . . . Bence, ACqul.ia
Discount $ ...... .......... Total area in sqnare feet ................
Net Paid $100. 00. _ . . , . , . Monument permitted . . . . . . . . . . . .�Zdt. . . . Route 1, Box 600A
(W. Main St)
(Data above this line for City Itecord only) City
R&R attached
C
�
Name
U�lit '" ei���"�`.
Block
Lot
Date of Mark-out
Date ofi Burial���9� Ti��. .� � �. �-r.:
/ ` -��? '--=�
Name of Funeral Home � d k �-���� �� �
Authorized by �: ._..� . � '
_ _.. _
_ _.
_ __ .
State of Florida, Departmen Heaith and Rehabilitative Services, Vital St 'stics` '. .��� �/�J ��
O APPLICATI�OR BURIAL — TRANSIT PERMIT � ,
A (Type or Print)
1. Name of First Middle ' Last DATE Month Day Year
Deceased OF
AQULIA BENCE <�EA7H Noven�ber 22, 1991
2. Place of Death City, Town or Location Name of ,(If neither, give street address)
Counry Hosp. or
Indian River „ Vero Beach Inst. Indian River Memorial Hoapital
3. Name of Medical
Certifier
E. Duane Dilley, M.D.
Medical Examiner Address
2300 5th Avenue
Physician Vero Beach, Florida 32960
4. Name of Funeral Home/ Address Fla. Lic. No./Reg. No.
Direct Disposer _ Cox-Gifford 1950 ZOth Street
Funeral Home Vero Beach FL 32961
5. Check
Appro-
priate
Box
6• Place of
Fina! Disposition:
�• Funeral Director/
Direct Disposer
�
The medical certification has been completed and
this application.
� 1423
signed. A completed cert
Nnone Number
(407) 567-7111
Phone Number (Area Gode)
(407) 562-2365
of death accompanies
b❑ X E_. TM�anu+ il; l l ov Ht il was contacted on � � ��� �o+ within 72
Mours 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 �, n+�����e���. n. will complete
and sign the medical certification of cause of death.
�❑ was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
medical certification.
In state cemetery/
crematory - name/county:
Removal
n from state n Donation
F.E. No./Re . Na Date Signed
� 5�3� i1/Or/. �3 �
� BURIAL — TRANSIT PERMIT
Permit No. rc���,.��6g��1
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 irom filing within the normal time limit. lf 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.
Registrar or Date Date Certificate
�ih �1 �a� C�-1.�� Issued: ���l.�y[9� Due:
Subrzgistrar Signature /1 �
C.
�
Signature
or
AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA
, Medical Examiner Date
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. _
Methods of Disposition:
� BURIAL
❑ CREMATION
Sic�nature of Sexton )
or Person-in-Charge )
❑ STORAGE
❑ OTHER (Specify)
. .
�
CEMETERY OR CREMATORY
Place of Disposition Sebastian CPSnetery
Date of Disposition November 25, 1991
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.
�IRS Form 326, Feb 89 (Replaces Oct 87 edition which may be used)
(Stock Number: 5740-000-0326-2)