HomeMy WebLinkAbout2-13-06SHEET NO.
TERMS
RATING
DEED #398`'
WATERS, i Mrs. Lewis (Nancy)
P. O. Box 801
Sebastian, Fl (Russell St in Roseland)
BLK 13, Lots 6 & 7 Unit 2
Husband: Lewis Waters interred 515180
�47 V
Name
Unit
Block '
Lot �•
Date of Mark -out
Date of Burial `' 1 �' Time / L
Name of Funeral Home_
Authorized by`_'_
Paid by General Receipt No. ......1.89 .. .... Dated... May..7,,, , Z,980..........
Last Price $.. ?00 .00 .. _ .. . Maximum No. Burial spaces ........ 2.. .
Discount $ .................. Total area in square feet ................
Net Paid $, 200.00........ Monument permitted ..... FZa.t..........
R &R attached (Data above this line for City Record only)
DEED #398
Mrs. Lewis Waters (Nancy)
(Russell Street, Roseland)
P.O. Box 801
Sebastian, Fl 32958
BLK 13 , Lois 6 & 7 ;Unit 2
Lewis Waters interred 515180
W PARTMENT OF ALT
A. (TYPE)
46
613
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
1. Name of First
Middle
Last
Date Month Day Year
Deceased
of
Nancy
Margaret
Waters
Death 5 -27 -01
2. Place of Death City, Town or Location
Name of (If neither, give street address)
County
Hosp. or
Brevard Melbourne
Inst. Holmes
Regional Medical Center
3. Name of Medical
Address
Phone Number
Certifier Roger Mittleman, M.E.
2500 South
35th Street
Medical Examiner MPhysician
Fort Pierce, FL 34981
( 561) 464 -7378
4. Name of Funeral Home /Direct Disposal
Address
Fla. Lic. No. /Reg. No.
Phone No. (Area Code)
Establishment
916 17th Street
Strunk Funeral Home
Vero
Beach, FL
32960
0130
(561) 562 -2325
5. Check a. The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. ❑
was contacted on
He /she verged that this death was from natural causes, that there was no accident nor other external cause of death,
and that will complete and sign the medical
certification of cause of death within 72 hours.
C. F1 was contacted on
He /she verified that
Medical Examiner, will complete and sign the
medical rtification f cause of death within 72 hours.
6. Funeral Director/ natur F.E. No. /R N D t Signed
Direct Disposer ' ! � /����
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. _ ' 0130-01-0271
A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has
been contacted by the funeral director and will not be able to complete the medical certification of cause -of -death section of the death certificate within
72 hours.
No extension of time for filing the death certificate has bee nested.
Registrar or Date Date Certificate
Subregistrar Signature Issued: 5 Q�R 10 IF _Due:
C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA
Approval Number: 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.
D. CEMETERY OR CREMATORY _
Method of Disposition: Place of Disposition % f3 d� 5 9 l� �y, k. tZ. / f e y.
BURIAL STORAGE Date of Disposition
CREMATION OTHER (Specify)
Signature of Sexton 1
or Person -in- Charge J}
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.
Distribution: White: Cemetery or Crematory
DH 326, 8/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number: 5740-000. 0326 -2) Pink: Local Registrar