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Paid by General Receipt No. ....18.0.......... Dated. ApxiZ . 1.5•r • 1980•
List Price 120,0.00.......... Maximum No. Burial spaces .......2...
Discount $.... ............. Total area in square feet ................
Net Paid $.20.0...00......... Monument permitted . , flat
(Data above this line for City Record only)
R &R Attached
DEED #.394
Rebecca G. & Paul J.Bergbo
IOTA N.Central A ve.,Sebast.
Lots 9 & 10, BIk 8, Unit #:
Paul to be interred 411718(
STATE OF FLORIDA
DEPARTMENT OF HEALTH & REHABILITIE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL— TRANSIT PERMIT
A.
(Type or Print)
Last DATE Month Day Year
1.
Name of First
Deceased
Middle
OF
Bergbom DEATH Oct . 6, 1983
Rebecca
Floyce
Name of (If neither, give street address)
2.
Place of Death City, Town or Location
Hosp. or
County '
Roseland
Inst. Sebastian River Medical Center
Indian River
Address
3.
Name of Medical
l
Fischer's Plaza Sebastian Florida
Certifier M. Nasir Rizwis
M.D. Medical Examiner
4.
Funeral Home/ Pottinger &Son
Name Address
Funeral Home 1200 S. Indian River Drive Sebastian Florida 32958
f death accompanies
5. Check a ®X The medical certification has been completed and signed. A completed cerbficate o
Appro- this application.
priate b � was contacted on . He /she verified that
Box 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.
❑ was contacted on . He /she verified that
c
,Medical Examiner, will complete and sign the
m i ification. ,%� (y► �9/'
Ir c
6. Funeral Director/ Sign re
Fla. Lic. No. /Reg. No. Date igned
�i+ret'BioPc+coc.'
BURIAL— TRANSIT PERMIT Permit No.
Permission is hereby granted to dispose of this body.
0 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 occurred.
Date i✓ �o� 193
Registrar or Issued
Sub - Registrar Signature
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
10
, Medical Examiner Date
Signature
or
,gave authorization by telephone to
Medical Examiner,
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.
Y
Method of Disposition:
BURIAL ❑STORAGE
C] CREMATION n.OTHER (Specify)
Signature of Sexton 1
or Person -in- Charge .)
CEMETERY OR CREMATOR
Place of Disposition Sebastian Cemetery
October 8, 1983
Date of Disposition
This permit must be endorsed by the Sexton or person -in- charge (or b he Funeral irector /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, APR. 81
(replaces previous editions which may be used.)
0=1 CEM
Index:RECORD #
Last Name
Address i
Address 2
City
Deed #
Unit #
Lot Number
Lot Number
Lot Number
Lot Number
t
NEWCEM
City of Sebastian, FL - Cemetery Lots
BERGBOM First Name REBECCA G. & PAUL J.
101 -A NORTH CENTRAL AUE.
SEBASTIAN
394 Date
2- Block #
9 Interred
10 Interred
Interred
Interred
State FL
04 -15 -80 Amount
8
BERGBOM, PAUL J. (vet)
Rebecca Bergbom
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Friday, Jan 21, 2005 12:42 PM
Zip
$200
32958-
Dte Interred 04 -12 -80
Dte Interred - -83
Dte Interred
Dte Interred
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