HomeMy WebLinkAbout2-06-11Paid by General Receipt No. .16Z OCt 12, 1979
. Dated ............... ...............
List Price $ „* *,300.00 **
Maximum No. Burial spaces ..... 3
Discount $ ......... -........ Total area in
square feet ...
Net Paid $.... 300 . Q0, , , , . Monument • ........ .
permitted .....................
R &R Attached
(Data above this line for City Record onlv)
DEED #375
Mrs. Anna Pappas (Peter)
10 Sunset Dr
Roseland
P. O.Box 362
Sebastian, F1
6/1ii8E .,
#2
�]
STATE OF FLORIDA'
DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT
A.
(Type or Print)
1.
Name of
First Middle Last
DATE Month Day. Year
Deceased
OF
Helen Dulseno
DEATH April 28 1982
2.
Place of Death
City, Town or Location Name of
(If neither, give street address)
County
Hosp. or
Inst.
Sphastian River Mpdiral Cp_ntp_r
3.
Indian River
Name of Medical
Roseland
[Z Physician
Address
Certifier Kathy S Doner,
M D E] Medical Examiner Roseland
Plaza Suite 12_Spbastian, Fla -
4.
Funeral Home/
Name
Address
Direct Disposer Cox Gifford Roma_n_iI_ P A. 1950 2fth S rpet, P
0 Box 1113. Vprn Rparh- Florida 3r
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b ® Dr Donpr was contacted on
. 114 /she verified that
Box
this death was from natural causes, that there was no accident nor other external cause of death, and that
she will complete and sign the medical certification of
cause of death.
c ❑ was contacted on . He /she verified that
Medical Examiner, will complete and sign the
medical certification.
6. Funeral Director/ ature Fla. Lic. No./Fig1 ININ• Date Signed
dfiXelE3(K1Xs�6X#�1( ��
William G. Romani #1550 April 29, 1982
B
BURIAL — TRANSIT PERMIT
Permit No. 5- 098 -1982
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 occurred.
Registrar or y Date April
29, 1982
v
Sub- Registrar Signature —+l- Issued OF
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:
® BURIAL ❑ STORAGE
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton
or Person -in- Charge )
CEMETERY OR CREMATORY
X,
Place of- Disposition Sebastian Cemetery
Date of Disposition May 1, 1982
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, APR. 81
(replaces previous editions which may be used.l