HomeMy WebLinkAbout2-05-06DEED #372
Cogburn Jr., Jesse D. (deceased) EED #372
BLOCK 5 LOT 6 UNIT #2
Deed made out to Lawrence & Rachael Schmidt
507 Circle West
Jupiter, Fl 33458
i
Schmidt,-Lawrence & Rachael DEED #372
507 Circle West
Jupiter, Fl 33458
BLOCK 5 LOT 6 UNIT #2
for: Jesse D. Cogburn, Jr. (deceased)
Xfiled under "Cogburn"
ILOMDA
DEPARTMENT OF HEALTH AND REHASILITATIVE SERVICES
VITAL STATISTICS % CO ICJ
APKICATMN FOR amm
NAME OF First
DECEASED
Mlddle lest
ATE Month Day Yisar
OF
IType or print) Jesse
DEATH Sep. 27, 1979
PLACE OF DEATH
COON Y
CITY, TOWN, OR LOCATION
NAME OF
HOSPITAL OR
Ill not in hospital, give street address)
nd i an River
INSTITUTION
Indian River Mem. JoVJU
Attending Physician ❑
(Norm of Medical Certifier)
(Address)
Medical Examiners ❑ Dr. Michael B.
Zimmer, 2300 5th Aye% . Vero Beach, Fla. 32960
Funisro
Home !Floyd /Strunk "Pu"Weral Home,
.
2405 14th Ave. Vero Beach,
Fla. I
Check A ❑ A completed certificate of death accompanies this application.
One
Funeral
Director
m)ner Sep. 29, 1979
B [] ?i
Dr. was contacted on , 19
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
(Fla. Lic. No.) (Date signed)
Permit
No. 1 13-525
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.
I] A five day extension of time for filing the death certificate has been requested and grantoO.
Signature of� 1
Registrar
P Date
- Issued Sep. 28, 1979
CMIAl1'IIRY OR CwIAATawy
Method of Disposition Date of /� �, -__
❑ BURIAL Disposition
❑ CREMATION
❑ STORAGE Place of
❑ OTHER (Specify) Disposition���
Signature of Sexton
or Person in Charge `t, JJ `
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.
HRS Form 326 (1/77)
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