HomeMy WebLinkAbout2-13-02SHEET NO.
TERMS
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DEED #392
Paid by General Receipt No. . 178 , . . . . . . . , . , Dat�. .4/3�8Q .
..................
COMBES, Vernon W. or Gertrude A.
List Frice �.*.*.2QO..O.Q.*.*.... Maximum I�TO. Burial spaces .....2...... �945 Brevard Avenue
Discount ....... Total area in s Roseland, FI 33957
$.... �..... quare fcet ................
Net Paid $**?00,.,00 ** , _ . Monument pe�rmitted . . . fldt. . . . . . . . . . . , BLK .I 3 T�6TS -.�&� UNIT #2
R&R attdChed (Data above Yhis line for Gity R,ecord only)
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Nar�e Y G �,�?� t� / � t� � c;' .��"'! ,�'� �-� 't�a`
Unit «�-�
Block
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Lot �'�
Date of Mark-out
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.� r� /' � � �� ` � g � ' wsi�a
Date of Burial
� Time � � l
Name of Funeral Hom� �% '� � '�� �"�
Authorized by °'" .—a' r ,_ ' .
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STATE OF FLORIDA � ��
� �PARTMENT OF HEALTH & REHABILIT�E SERVICES
VITAL STATiSTICS � �
�Nl� IAtlII.ITATIV�I�]I�:NV1K:ISU . . .. . � .
APPLICATION FOR,BURIAL—TRANSITPERMIT
%�• (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
VERNON W. COMBES DEATH 1�1ARCH 3, 1989
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
INDIAN RIVER ROSELAND Inst. HUMANA HOSPITAL—SEBASTIAN
3. Name of Medical �hysician Address Phone Number
Certifier NASIR RIZWI, M.D. ❑ Medical Examiner 13865 US��1 SEBASTIAN, FLA 407-589-6844
4. Funeral Home/ Name Address Phone Number (Area Code)
�1�ffi]�}4�K STRUNK FUNERAL HOME 1623 N. CENTRAL AVE. SEBASTIAN, FLA 407-589-1000
5. Check a❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
goX b�] EDIE was contacted on 3/3/89 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 DR. RIZWI 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.
6. Funeral Director/ ignature
�LXB�C�i�i�X�f /l «t /
,r Fla. Lic. No./Reg. No. Date Signed
,�� ��1672 3/3/89
B• BURIAL—TRANSIT PERMIT �
Permission is hereby granted to dispose of this body.
Permit No. 1228-89-116
❑ A five day extension of time for fifing 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 ReporY' will be filed with the Local Registrar of the Counry in which death occurred.
❑ No extension of time for filin he death certificate requested.
Registrar or - Date Datz Certificate
Subregistrar Signature Issued: - 3�3�8� Due:
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. -
0. ,
� ' CEMETERY OR CREMATORY
Method of Disposition:
� BURIAL ❑ STORAGE
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person-in-Charge )
Place of Disposition SEBASTIAN CEMETERY
Date of Disposition
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 County Health Department in the County where disposition occurred.
HRS Form 326, Oct 87 (Replaces May 86 edition which may be used)
(Stock Number: 5740-000-0326-2)