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Block 9, lots 1& 2, Unit 2
�
Carl & Helen Lee
857 Lance Street
Sebastian
He1en interred 9/15/80
Deed #411
Paid by G�n�Ma�Receipt No. .203....... .... Data1.....5@,Pt...1Zl..1980....
List Price $... *2QQr.Qp*...
Discount $ ......... ........
Net PaId $, , ,'"�00 . 00 *
:Kaxfmum No. Burial apaces . . . ,� . . . . . . .
Total area in square foet ................
Monument permitted . . . . . FI a t , , , , , , , , , ,
�� � (Data above thls llne for City R.eeord only)
Car1 and He1en�.:7e.e, �•
857 Lance St., Seb.
Deed # 4Z1
Block 9, lots 1& 2, Unit
Helan interred 9/15/80
_ -- -- __.
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STATE OF FLOfiIDA / �c{
OEPARTMENT OF HEALTH ANO REHABILITATIVE SERVICES /� �'" «�./ �� ��
VITAL STATISTICS
�APPLICATION FOR BURIAL-TRAN�SIT PERMIT
NAME OF Fint Midd1• last DATE Month Day re.r
DECEASED p ATH$g tember 13' 1980
(Typa o► print) Helen Frances Lee
PLACE OF DEATH CITY, TOWN, OR LOCATION NAME OF (lf not in hospital, pive �Itre�t �ddrsssl
COUNTY HOSPITAL OR
Brevard Melbourne �NSTITUTION�jp],mgg Re ional edical C
Arnndinp Physici�n [yd IN�me of Medicsl Cartifier) (Addrass)
M�diul Exsmi�... ❑ R. C. See]anan, M. D. , 200 East Sheridan Road, Melbourne, Fla. i 32901
Fu��nl INama1 (Addrets)
Hom� Cox-Gifford-Baldwin Funeral Home, 1950 20th St., Vero Beach, F1a. 32960: _
Check A❑ A completed certificate of death accompanies this application.
One
B�] Dr. R � ��A��++an was contacted on S�„* � 3 �•19—�II—•
He has assured me that this deatfi was fran natural causes and that he will complete and sig� the medical
certification of cause of death. '
C❑ The attending physician was unavailable or thia death comes within the Medical Examiner�s jurisdiction.
The body was released to me by
o� ,T9 . :
lSipnsturel lFla. Lic. No.) IDate Siyned)
Funeral � '
Director t� /�� #868 Sept. 14, 1980
_ .. _ _ Permit
r BURIAL TRANSIT PERMIT No. 5�^�-1880 �
Permission is hereby granted to dispose of this body by burial, transportation out of state, storage or cremation. Fi�r cremation a
waiting period of 48 hours after death must be observed and the Medical Examiner's approval must also be obtained;
[,� A five day extension of time for filing the death certificate has been requested and granted.
Signature of
Registrar
Method of Disposition
� BURIAL
[J CREMATION
� STORAGE
� OTHER1Specify)
Signature of Sexton
or Person in Charge
0
�
.
Date
Issued Sept. 14, 1
tEMETERY OR CREMATORY
Date of
Disposition Set�tember 15 1980
Ptace of Sebastian Cemetery
^-�ast- n Indian River ��.. Fla.
Diaposition � � .
This�permit must be endorsed by the xton or person in charge (or by the funeral director when there is no sexton) and retumed
within 10 days to the Ixal county health department
HRS Form 326 (1/771•