HomeMy WebLinkAbout2-09-14Francis & Rosalea Peltiei-
CEMFf 204 1 J 856 Lance St., Seb.
Paid by General Receip No . .................. Dated..... SL.'P.t., . A5'. 1980 ....
*200;00* Deed # 412
List Price $..... Maximum No. Burial spaces ..2........
Discount $ ........ 7 ......... Total area in square feet ................ Block 9, lots 13, & 14
Net Paid $..... *.2A.0.•.OD. *... Monument permitted ...... Flat ........ Unit 2
9 � R (Data above this line for City Record only)
Lot %f
Date of Mark -out
Date of Burial Time
Name of Funeral Home ' '�
Authorized by
STATE OF FLORIDA �/
IS ARTMENT OF HEALTH & REHABILITA SERVICES A
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT Z/ Oq
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
DEATH FRANCES ROSALEA PELTIER JULY 9„ 1989
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
INDIAN RIVER SEBASTIAN Inst. 856 LANCE STREET
3. Name of Medical
❑ Physician Address
464 -7378 Phone Number
Certifier FREDERICK ROBIN, ME.
[$ Medical Examiner 2500 S. 35TH. ST.
FT. PIERCE, FLA
4. Funeral Home/
Name
Address
Phone Number (Area Code)
DAXKD i=r
STRUNK FUNERAL-.HOME
1623 N. CENTRAL AVE. SEBASTIAN, FLA
407- 589 -1000
5. Check
Appro-
a ❑ The medical certification has been completed and signed. A completed
this application.
certificate of death accompanies
priate was contacted on within 48
Box b ❑
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 will complete
and sign the medical certification of cause of death.
c ) HELEN was contacted on . He/she verified that
DR. FREDERICK HOBIN, M.E. Medical Examiner, will complete and sign the
medical ,ortification. /J /
6. Funeral Director/ � � // Sin fture • Fla. Lic. No. /Reg. No. bate Signed
#1672 7/11/89
B. BURIAL— TRANSIT PERMIT Permit No. 1228 -89 -308
Permission is hereby granted to dispose of this body.
❑ A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted. If it cannot be filed
within this time limit, a "Funeral Director /Direct Disposer Report" will be filed with the Local Registrar of the County in which death oc-
curred.
❑ No extension of time for filing the death certificate requested.
Registrar or
Sub - Registrar Signature &"L�o AL.
Date 7/11/89
Issued:
Date Certificate
Due: —
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
M
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.
Method of Disposition:
U BURIAL ❑ STORAGE
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or e )
CEMETERY OR CREMATORY
Place of Disposition SEBASTIAN CEMETERY
q
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, May 86 (Replaces Apr 81 edition which may be used)
(Stock Number: 5740.000- 0326 -2)