HomeMy WebLinkAbout2-05-14Name
Unit,�—
Block
Lot
Date of Mark -out._
Date of Burial
Name of Funeral Home
Authorized by_
(Data above this line for City Record only)
R &R Attached
DEED
#374
Paid by General Receipt No.16Q ...............
Dated . ], O- Jr.- 79...................
Martha C.
Brady
Roseland
Road
List Price $200.00 ......... .
Maximum No. Burial spaces ..iR ........
Roseland,
Sebastian, F1
Discount $ ..................
total area in square feet ........
LOTS 13
& 14 BLK 5 #2
Net Paid $200 .00
Monument permitted ...... Flat
(Data above this line for City Record only)
R &R Attached
Y STATE OF FLORIDA
�RTMENT OF HEALTH & REHABILITATIVERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT
F
� ry
41
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
William Michael Brady DEATH October,9, 1987
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Brevard Melbourne Inst. Holmes Regional medical center
3. Name of Medical n Physician Address
Certifier Charles Croft, M. D. [:]Medical Examiner 200 E. Sheridan Rd., Melbourne, Florida
4. Funeral Home/ Name Address
Direct Disposer Browrtlie & Maxwell Funeral Hone, 1010 E. palmetto Ave., Melbourne, F14rida
5. Check a 0 The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b Croft was contacted on s office
Box � �' 10/9/87 . He /she verified that
this death was from natural causes, that there was no accident nor other external cause of death, and that
II complete and sign the medical certification of
cause of death.
c 0 was contacted on . He /she verified that
Medical Examiner, will complete and sign the
medical certif' t'on.
890 October 9 1987
6. Funeral Director/ Signature Fla. Lic. No. /Reg. No. Date Signed
Direct Disposer
B. BURIAL — TRANSIT PERMIT 49BC20
Permit No.
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 Regis ar f the unty in which death occurred.
Registrar or Date October 9, 1987
Sub- Registrar Signature Issued _/z
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
Signature , Medical Examiner Date
or
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.
D. CEMETERY OR CREMATORY Sebastian Cemetery
Method of Disposition: Place of Disposition Sebastian, Florid$
BURIAL [] STORAGE Date of Disposition
CREMATION C] OTHER (Specify)
Signature of Sexton
or Person -in- Charge ) dsigi St. _
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.)