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HomeMy WebLinkAbout2-06-01DEED # 379 165 October 22 1979 Denny or Joanne Roya Paid by General Receipt No. Dated.... �........... [fin. Henry Thompson List Price (1 to red ..1QO..OQ ....... Maximum No. Burial spaces ..1......... Rt . 1, BOX 31 -A Discount $.7777 .. square feet 7777 Roseland, F1. ......... Total area in ................ Net Paid $. I.OQ . QO........ Monument permitted ..Flat ............ . Blk. 6, Lot 1, Unit R & R attached (Data above this line for City Record only) O �e v o /i ✓' p1� f � Block 6 Lot 1 Unit 2 DEED # 379 i Wm. Henry Thompson ( interred 10- 23 -79) Denny & Joanne Royal Rt. 1, Box 131 -A Roseland, F1. JINI t. UT' VLVKIV- DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES VITAL STATISTICS APPLICATION FOR BURIAL -TRAM PERMIT NAME OF First DECEASED �� n Middle i' lost 1 �f n DATE Month Day Year E I, /' / 77 DEATH J )Type or print) �C/ PLACE OF DEATH F --✓V CITY, TO , OR LOCATION NAME OF MOSPITAI OR "�� III not in hospital, give street address) COUNTY` G bbblll INSTITUTION !C Attending Physician ❑ (Name of Medical Certifier) IAddr I �L Medical Examiners ❑ &-) ) .S S ,�k r Vtzgip /t Funeral �-+ (Name( ` 1"�� � (Add *I A 1--4, Home / p .1 r Gf M�K u Q.)� /Q�A eg � a� T p i� UE _�'�L�fL_ Check A ❑ A completed certificate of death accompanies this application. One B [j Dr. M y s,� was contacted on �9 19 -1. He has assured me that this death was from natural causes and that he will complete and sign the medical 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 on , 19 ✓ 19kA de/I. 02�. — — IS nature) ��_..,L (Fla. Lic. No.) (Date Signed) Funeral %% r Director (d (�J BURIAL TRANSIT PERMIT 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 4B 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 �� //y1 /� Date Registrar Issued 44p 1Y % CEMETERY OR CREMATORY Method of Disposition Date Disposition BURIAL sition ❑ CREMATION , E] STORAGE Place of ❑ OTHER (Specify) Disposition _ - 1 Signature of iestew -a# Person in Charge This permit must be endorsed by the sexton or person in charge (or by the funeral director when there is no sexton) and returned within 10 days to the local county health department. HFAS I orm 326 (1/77)