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DEED #399
Paid by General Receipt No. ....180..... .... Dated. Ap—il . 1.5•r . Z980• • . • . • .. Rebecca G. & Paul J. Bergb
List Price 2 101A N.Central Ave.,Sebas
X204.40• • • • • • • • Maximum No. Burial spaces ........ .
Discount $ ....7 ............. Total area in square feet ................ Lots 9 & 10, Blk 8, unit
Net Paid $.20.0...00......... Monument pefmitted flat
R &R Attached Paul to be interred 41171
(Data above this line for City Record only)
BLOCK 8 LOTS 9 & 10
UNIT #2 DEED 394
Mr. and Mrs. Paul J. Bergbom
101 -A North Central Avenue
Sebastian , F1
Paul J. Bergbom interred 4117180
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES 9��D
VITAL STATISTICS
�POAPPLICATION FOR BURIAL -TRIT PERMIT
DATE Month Day Year
F irst Middle Last OF
NAME OF DEATH A
DECEASED Paul Joseph Be- bon►
(Type or print) NAME OF (If no�mh ital, give street address) PLACE OF DEATH CITY, TOWN, OR LOCATION HOSPITAL OR
COUNTY RpBel INSTITUTION Seb s Indian River dress)
Attending Physician ® (Name of Medical Certifier)
Medical Examiners ❑ Farhat Khawajap M.D. S. U.S. # 1 Sebastian Florida 32958
(Address)
Funeral (Name)
Home Colonial Funeral Home S. Indian River Drive Sebastian Florida___339� -$. —
Check A [�& A completed certificate of death accompanies this application.
One
❑ --
was contacted on -- - _.
B Dr. _ 19
He has assured me that this death was from natural causes and that he will complete and sign the medics
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
' 19
Qn
IOate Signed)
(Signature) )Fla. Lic. No l
Funeral
Director
Permit 7V'
BURIAL TRANSIT PERMIT No
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.
[] A five day extension of time for filing the death certificate has been requested and granted.
Date
Signature of Issued
Registrar --
CEMETERY OR CREMATORY
Method of Disposition Date of
I BURIAL Disposition _ April 17, 180
CREMATION
STORAGE Place of Sebastian Cemetery
Disposition
1 OTHER(Specify)
Signature of Suter► /
or Person in Charge e
rge (or by the funeral director when there is no sexton) and returned
This permit must be endorsed by the sexton or person in cha
witlim 10 days to the local county health department.
HfiS Form 326 11/77)