HomeMy WebLinkAbout2-13-04SHEET NO.
TERMS
RATING
wun"Jul- 3l4U- UUU- Ua26 -2)
Paid by General Receipt No. ...1g3.... Dated— Mats 28, 1.980
List Price 350.00.... Maximum No. Burial
$........... spaces .i .......
...
Discount $...... - .......... Total area in square feet ................
Net Paid $..350.00 Monument permitted ..... flat
........ .............
t &R Attached (Data above this line for City Record only)
NaMC.
Unit
3
Block L':
Lot — "1/
Date of Mark -out �: � % /
Adkins, Mr. Ivan H. DEED #402
P. 0. Box 45
Fellsmere, F1
Blk 13 Lots 3 & 4 Unit #2
Wife: Jeannette S. inti?rred
5/3/80
Date of Burial /
Time
Name of Funeral Home—
Authorized by
STATE OF FLORIDA !,
D RTMENT OF HEALTH & REHABILITATII ERVICES
VITAL STATISTICS
OFYAXTNI'.NT OF NEALTN AND '
NF. "" TTIAT -11 "�:, APPLICATION FOR BURIAL — TRANSIT PERMIT �....
A. (Type or Print)
1. Name of First Middle
Deceased Last DATE Month Day Year
IVAN HAROLD ADKINS OF AUGUST 20, 1989
2. Place of Death City, Town or Location
DEATH
County Name of (If neither, give street address)
BREVARD EAU GALLIE Hosp. or
Inst. 1900 W. SHORE DRIVE
3. Name of Medical M Physician
Certifier Address 725 -4500 Phone Number
JOSEPH A. M CLURE M.D. p Medical Examiner 200 E. SHERIDAN ROAD, MELBOURNE, FLA
4. Funeral Home/ Name
Direct Disposer Address Phone Number (Area Code)
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro• this application.
priate � DR, MCCLURE
Box b was contacted on 8/20/89 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
and sign the medical certification of cause of death. will complete
c was contacted on
. He /she verified that
medical certification.
Medical Examiner, will complete and sign the
6. Funeral Director /
Direet- Bisposer
B.
Fla. Lic. No. /Reg. No. Date Signed
#1672 8/20/89
BURIAL— TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228-89-381
❑ 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 f) Mg g the death certificate req sted.
Registrar or Date
Subregistrar Signature kC'_ _ ' i 8/20/89 Data Certificate
Issued: Due:
AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
Signature
or , 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.
CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition SEBASTIAN CEMETERY
XE] BURIAL ❑ STORAGE Date of Disposition AUGUST 22, 1989
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person -in- Charge) Z% if , - -A e-21( .
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.
S Form 326, Oct 87 (Replaces May 86 edition which may be used)
Eck Number: 5740 - 000 - 0326 -2)