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Pafd by General Receipt No. ... Zg3''.'. ... ... .. Dated... Ma� . 28,.. . Z980
List Price ;..350,,00....... Muximum No. Burial spaces .2..........
Discount $...... -.......... Total area in square fcet
................
Net Paid $, .350 . 00 Monument permitted ...., fZ a t
'.&R AttaCh@d (Data above 1�is liae for City Record only)
BLOCK Z 3 LOTS 3& 4 UNIT #2
Ivan H. Adkins
P. O. Box 45
Fellsmere, F.i 32948
Jeannette S. interred 5/3/80
Ivan H. interred 8/22/g9
:. _
Adkins, Mr. Ivan H. DEED #40� '
P. O. Box 45
Fellsmere, FZ
BIk 13 Lots 3& 4 Uni t#2
Wife: Jeannette S. in�'erred
5/3/80
DEED #402
S7ATE OF FLORIUA
� DEPARTMENT OF HEALTH AND RENABIUT IVE SERVICES �� �`� � p�
VITAL STATISTICS �
APPLICATION FOR BURIAL-TRANSIT PERMIT
NAME OF First Middle Last DATE Month DaV Vear
Type oSprD�int1 Jeanette S. Adklns D ATH May 1� 1980
P�ACE OF DEATH CITV, TOWN, OR LOCATION NAME OF (lf not in hospital, give street addressl
COUNTY HOSPITAL OR
indian River Fellsmere INSTITUTION Orange & Maryland
Attending Physician [] (Name of Medical Certitier) (Address)
Medical Examiners L� H. L. Schofield� Jr. M.D. 1503 24th St. Vero Beach Florida32960
Funeral (Name) � (Address)
Home Colonial Funeral Home S. India.n River Dr. Sebastian Florida 32958
Check
Une
,\ (
����
Funeral
Director
A�] A completed certificate of death accompanies this application.
B❑ Dr, was contacted on ,19
He has assured me that this death was from natural causes and that he will complete and sign the medical
certification of cause of death.
C❑ The attending physician was unavailable or this death comes within the Medical Examiners jurisdiction.
The body was released to me by
ISignature)
_ ,19
1579
(Fla. Lic. No.l
BURIAL TRANSIT PERMIT
May 2, 1980
(Date Signed)
Permit �� q �� �O
N o. !
Permission is hereby granted to dispose of this body by burial, transportation out of state, storage or cremation. For cremation a
waiting period of 48 hours after death must be observed and the Medical Examiner's approval must also be obtained.
c:,.....«...,. ,.s
❑ A five day extension of time for filing the death certificate has been requested and granted.
n �,o
�.4ethod of Disposition
;� BURIA�
i-1 CREMATION
[� STORAGE
�� OTHER�Specify►
CEMETERY OR CREMATORY
Date of . pqay 3, 1980
Disposition
Place of Seba.stian Cemetery
Disposition
Signature of•Sex�teq �
er Person in Charge ,-� �[� �- _ �j�,.�
�-/ �LG � c c: - L L.����t c2-�_.
This permit must be endorsed by the sexton or person in charge (or by the funeral director when there is no sexton) and returned
wiihin 10 days to the local county health department.
HRS Form 326 (1/77)