HomeMy WebLinkAbout2-06-136A44BE
Paid by General Receipt No. .,163............ Dated.10716- 79 ................
List Price $.240,.00......... Maximum No. Burial spaces .2..........
Discount $ .................. Total area In square feet ...............
Net Paid $200 .00......... Monument permitted .f�At; ..............
R &R attached (Data above this line for City Record only)
Name JJ 11/lI
Unit
Block
Lot 13
Date of Mark -out
Date of Burial ,./.. q '/ - Z...1 Time
Name of Funeral Home 'Vi ty 1 I t.
Authorized by__
DEED #377
Henry & Aphrodi to Pres ton
665 SW Vocelle Ave
Sebastian
LOTS 13 & 14 BLK 6 UNIT #2
BLOCK 6 LOTS 13 & 14 UNIT #2 DEED #377
Henry and Aphrodite Preston
665 SW Vocelle Avenue
Sebastian, F1
Aph l In Ile r Ir ecJl.,
� -o't `F'
CITY OF SEBASTIAN 0567
CITY CLERK'S OFFICE
RECEIPT
❑ Cash
Name. J ,�
- Check#
Date
AmountPald
001001208001
Sales Tax
001501322900
Garage Sales
001501341920
Copies/Bid Specs. �-
001501341910
LDC1code of Ordinances �-
001501362100
Community Center Rent
001501362100
Yacht Club Rent �-
001501 362150
Non Taxable Rent �-
001501343800
Cemetery Lots �-
601010 343800
Cemetery Lots
Lot/Niche —. _, Block —, Unit
001501369400
Interment Fee
001501369400
Weekend Service —�-
680800 220681
Yacht Club Security Deposit
680800 220682
Community Center Security Deposit - -- ----'
680800 220683
Riverview Park Security Deposit
r
Total Paid
Initials
White — Ospt. of Origin • Yellow — Finance Pink Applicant'
Number
This package contains the cremated remains of
LLLJl1- _ --
Death 03 -17 -2002
Birth 01-20-1908 Months ___ Days
Years
Age: —94 q day of
21st Y March , 20 0? —
Cremated this
Cremated by
MEMORY GARDENS OF LAS VEGAS, NEVADA
7251 S LONE
NEVADA 8gN 0AD
9
A
10� STATE OF NEVADA - DEPARTMENT OF HUMAN RESOURCtS
�'1 �d DIVISION OF HEALTH - SECTION OF VITAL STATISTICS -I
6,aA� BURIAL- TRANSIT PERMIT F I . /4 1 �G� STATE FILE NUMBER
LOCAL FILE NUMBER
DECEASED -NAME �Ea First Middle �t AYLaaIsstt DATE March DEATHH.., Month, Dayn�Yearn),�f COUNTY OF DEATH
Hattry' P1C�E.;TON 2. March A l 6114 3a. Cla k
CITY, TOWN OR LOCATION OF DEATH HOSPITAL OR OTHER INSTITUTION-Name (If not elther, give street and number) Fm.l patients(Specfy) DOA, OP /Emer. SEX
3b. Las Vegas 3c. Nathan Adelson Ho s ice 3e. Ix! altient 4.
RACE -(e.., White, Black, American Was Decedent of Hispanic Origin? Specify ❑ yes no If yes, AGE -Last UNDER 1 YEAR UND R 1 DAY DATE OF BIRTH (Mo., Day, Yr.)
Indian, etc.) (Specify) specify Mexican, Cuban, Puerto Rican, etc. Birthday (Years) MOS ; DAYS HOURS MINS 20,
5. Whig 6. 7a. 94 7b. ; 7a 6� Jail
STATE OF BIRTH CITIZEN OF WHAT COW Decedent's Education. Specify highest MARRIED, WIDOWED, NEVER
DIVORCED RMARRIED, SURVIVING SPOUSE (If wife, give maiden name)
(If not U.S.A., name country) TRY grade completed. y)
9a.Ma�ssachusetts 9b. USA ,o. 12 ,1. Wido�fe�! ,2.
SOCIAL SECURITY NUMBER USUAL OCCUPATION (Give Kind of Work Done During Most of KIND OF BUSINESS OR INDUSTRY
14a. Mac:hinest. 14b. ale tZt'yFii !�
RESIDENCE-STATE COUNTY !n CITY, TOWN, OR LOCATION STREET[�AgNDt4NUMadagascar MBER t �SpecilyCYes or l N.)S
15a. 15b. Clark 15c. Las VES ��'+ 15d. 1920 M1�15e. VUlg
FATHER -NAME John Middle Last MOTHER - MAIDEN NAME tp F+iirrst Middle Last
16. John - PTO,6t'a -i Is 17. Eithesla Alexander
INFORMANT -NAME (Type or Print) MAILING ADDRESS (Street or R.F.D. No., City or Town, State, Zip)
18a. George Thompson 161b. 51 Berkeley, Readin massechusf tte 01a67
BURIAL, CREMATION, REMOVAL, OTHER (Specify) CEMETERY OR CREMATORY- N,A3ME �+ LOCATION Vegas or Town State
19a. Cremation 19b. Memo Gardens Crema --- 19c. as Ile. Ate
FUN AL DIRECTOR- SIGNATURE FUNERAL DIRECTOR NAME AND ADDRESS OF FACILITY Bunkers Mortuary
(Or ferqon AcHng.,as. Such) LICENSE NUMBER
2oa:; °.:' LICENSE
20c. 925 Las Vegas Blvd. 2ti. Las Vegas, s die ada 899101
Z 21a.-To , the best of my knowledge, death occurred at the time, date and place and 22a. On the basis of examination and /or Investigation, in my opinion death occurred
T¢ due to the cause(s) stated. date
a at the time, date and place and due to the cause(s) and manner stated.
(Signature and Title) ` a; ,y„„...:� x� (Signature and Title) i
'wx DATE SIGNED (Mo., Day, Yr.) �,- S�FiOUR OF DEATH n0 DATE SIGNED (Mo., Day, Yr.) HOUR OF DEATH
na '..: n E �
tjZ 21 b. .' 21c. 7:45 ON u o 22b. 22c.
ro� - a `o PRONOUNCED DEAD (Mo., Day, Yr.) PRONOUNCED DEAD (Hour)
a- NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print) oU
0 r
U 21 d. 22d. ON 22e. AT
NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, ATTENDING PHYSICIAN, MEDICAL EXAMINER, OR CORONER). (Type or Print.) LICENSE NUMBER
23a. Kares3 oss o K& D * 4141 S . ensilaaa Las Ve as NV 89119 23b. ,,
REGISTRAR DATE RECEIVED 1£L TRAR o.c, Day. cYr. ) DEATH DUE TO COMMUNICABLE DISEASE
24a. ( Sgnature) / " -�63 .H33 24c. YES❑ NO
25. IMMEDIATE CAUSE ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (C).) 9 Y Interval between onset and death
PART (a) _
I DUE TO, OR AS A CONSE61J018E OF: Interval between onset and death
j (b) DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
if •
OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death but not resulting in the underlying cause given in Part 1. AUTOPSY (Specify WAS CASE REFERRED TO
PART g g Yes or No) CORONER (Specify Yes or No)
II 26. ji'R(i 27. y @,'
AUTHORITY FOR BURIAL, TRANSPORTATION, REMOVAL, CREMATION OR OTHER DISPOSITION
Having complied with all rules and regulations governing the preparation of dead human bodies and upon receiving the signatures of the person who is to certify the
cause of death, the funeral director or person acting as funeral director, and the local registrar, permission is granted to dispose of this body. The burial- transit permit
must be signed below by the cemetery or crematory authority. Where there is no full time person in charge of the cemetery the funeral director may sign as sexton.
Upon completion the permit must be returned to the local registrar where death occurred or to the funeral director.
BUNKER5_tIEMORY GARDENS
No `�� `LLB
. _. �. � 1
Signature of person in charge '%' �y Date 03 -21 -2002
of the cemetery or crematory { p�
A